HomeMy WebLinkAboutSeptic Pumping Slip - 16 CARLTON LANE 5/30/2017A. Facility Information
Important: When
filling out forms
on the computer,
use only the tab
key to move your Address
cursor - do not
use the return
key.
1. System Locatio
No Andover
City/Town
2. System OwRer:
(V)
Name
Address (if different from location)
City/Town
Commonwealth of Massachusetts
City/Town of NO ANDOVER
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date
accordance with 310 CMR 15.351.
:01
V.)
\N'cV
YO`
Slate Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: LI Cesspool(s) El Septic Tank El Tight Tank 111 Grease Trap
El Other (describe):
4. Effluent Tee Filter present? Ell Yes El No If yes, was it cleaned? El Yes Ei No
5. Observed opndition of component pumped:
Pumped By:
me
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
ture of Hauler
Vehicle License Number
Date
Signature of Receiving Facility (or attach facility receipt) Date
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System Pumping Record • Page 1 of 1