HomeMy WebLinkAboutSeptic Pumping Slip - 137 HAY MEADOW ROAD 5/1/2017Commonwealth 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 in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms 1. System Location:
use only the tab i 31 jkk ar ac..„h/(-) c 6
on the computer,
key to move your Address
cursor - do not
use the return
key
No Andover
CityfTown
2. System Owner:
VAC()
N
m
Address (if different from location)
City/Town
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: /5Gallons
-5
Date
3. Component: 111 Cesspool(s) D-8...;ptic Tank 111 Tight Tank El Grease Trap
Lil Other (describe):
4. Effluent Tee Filter present? 111 Yes 11.-"Flo If yes, was it cleaned? n Yes Eli No
5. Observed condition of component pumped:
6. System Pumped B
scx
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler
Vehicle License Number
Date
Signature of Ft....webir Facility (or attach facility receipt) Date
/I/
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1