HomeMy WebLinkAboutSeptic Pumping Slip - 71 CANDLESTICK ROAD 5/1/2017 Commonwealth nfMassachusetts
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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 basubstantially 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 |ooe| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CK8R 15.351.
A. Facility Information ("'Y'
Important:When u~
filling out forms 1. System LooaUo
nnthe computer,
use only the tab
key to move your xuummu
nu,onr do not
No Andover
use the return ---- --- ------'--------- ---
xay. oxW'mwn State Zip Code
2. System Owner:
VQ
Narne
xddmeo(if different from location)
otyTown State Zip Code
----------------
Te|ephon:Numbcr
B. Pumping Record
1. Ouha of Pumping2. Quantity Pumped:
Date 6allons
3. Component: F-1 Cesspool(s) ti smptioTank [l Tight Tank Fl Grease Trap
E] Other(describe): -------------------------
4� Effluent Tee Filter present? [l Yea ["o |fyes, was itcleaned? [l Yes 0 No
S. Observed condition rfcomponent pumped:
,
8. Pumped
wume Vehicle License Number
Stew-arts--SepticStew-arts--Septic 58 So Kimball St Bradford K4
Company
7. Location where contents were disposed:
,20 sq-0,41 stbradWd ma
Signature ofReceiving Facility(or attach facility receipt) oow