HomeMy WebLinkAboutSeptic Pumping Slip - 757 FOREST STREET 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'p
accordance with 310 CMR 15.351. e*C64111:"
A. Facility Information
Important: When
filling out forms 1. System Location:
on the computer,
use only the tab (*) bkrf
key to move your Address
cursor - do not No Andover
use the return
key. City/Town
2. System Owner:
,sbn
Name
Address (if different from location)
CityfTown
3,10
'rkeP\O't\ 00)Pall,let1
State Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
3. Component: 0 Cesspool(s) 0-Septic Tank 111 Tight Tank El Grease Trap
El Other (describe):
4. Effluent Tee Filter present? 0 Yes Erilo If yes, was it cleaned? El Yes El No
5. Observed condition of component pumped:
6. System Pump
1,4 trO 2-
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Vehicle License Number
Signature of Hauler Date
Signature of Receivq F5cility (or attach facility receipt) Date
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