HomeMy WebLinkAboutSeptic Pumping Slip - 121 FARNUM STREET 5/2/2017Important: When
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WW1
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
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
ny
ill
OVA in
„
0 016 91,:p 04)OER
WOO
Address
No Andover
City/Town
2. System Owner:
Name
/41
State
Zip Code
Address (if different om location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping CT) - 2. Quantity Pumped: 0 0
0-ate
3. Component: Cesspool(s) M'''Septic Tank r] Tight Tank 111 Grease Trap
ET Other (describe):
4. Effluent Tee Filter present? 11] Yes El No If yes, was it cleaned? Yes 111 No
5. Observed condition of component pumped:
v I(
( n v
6. System Pumped By:
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20so rn,iII st b dford ma
nature of il
Signature of Receiving Facility (or attach facility receipt)
(-
Gallons
Vehicle License Number
---
Date
Date
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System Pumping Record • Page 1 of 1