HomeMy WebLinkAboutSeptic Pumping Slip - 46 OXBOW CIRCLE 5/3/2017Commonwealth 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 Locatioo: •
on the computer, t, )) bt(k) use only the tab
key to move your Address
cursor - do not No Andover
use the return
key City/Town
2. System, Owner:
h
Name
0,1
State
Zip Zip Code
Address (if different from location)
City/Town
Telephone Number
B. Pumping Record
1. Date of Pumping
6-3
Date
Quantity Pumped:
/5 6
Gallons
3. Component: LI Cesspool(s) Septic Tank El Tight Tank El Grease Trap
El Other (describe):
4. Effluent Tee Filter present? El Yes D No If yes, was it cleaned? D Yes LI No
5. Observed condition of component pu
6. ysterfumped B
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 s mill s ma
Signat e of Hauler
Vehicle License Number
Date
g ature of Receiving Facility (or attach facility receipt) Date
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