HomeMy WebLinkAboutSeptic Pumping Slip - 796 WINTER STREET 5/1/2017Important: 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 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
1. System Location:
Address
No Andover
City/Town State
2. System Owner:
Name
Address (if different from loca(ion)
Cityrrown
B. Pumping Record
1. Date of Pumping
Date
1-11
Zip Code
State Zip Code
Telephone Number
2. Quantity Pumped:
Gallons
3. Component: LI Cesspool(s) ra'<ptic Tank El Tight Tank El Grease Trap
El Other (describe):
4. Effluent Tee Filter present? 0 Yes
5. Observed condition of component pumped:
6. System Pumped
Name
Stewarts Septic 58 So'Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
ee.
Signature of Hauler
If yes, was it cleaned? 111 Yes 0 No
Vehicle License Number
Date
Signature of f3 -Factilty"Contta—c-FaCilif-r-eceipt) Date
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