HomeMy WebLinkAboutSeptic Pumping Slip - 356 RALEIGH TAVERN LANE 5/30/2017Important: When
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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 .ubmitted to
the local Board of Health or other approving authority within 14 days from the 04 II e in
accordance with 310 CMR 15.351.,
A. Facility Information
1.
System Location:
E
Address
No Andover
City/Town
2. System, Ow er:
-i„n
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
State
Zip Code
State Zip Code
Telephone Number
Date 2. Quantity Pumped:
3. Component: CI Cesspool(s) Ereptic Tank
[I] Other (describe):
4. Effluent Tee Filter present? E] Yes CI No
5. Observed c ndition of component pumped:
6. System Pumped By:
e arts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Sign e of Hauler
Signature of Receiving Facility (or attach
Gallons
111 Tight Tank El Grease Trap
If yes, was it cleaned? EJ Yes El No
Vehicle License Number
acility receipt) Date
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