HomeMy WebLinkAboutSeptic Pumping Slip - 17 CROSSBOW LANE 5/4/2017Important: 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 R cord must be submitted to
the local Board of Health or other approving authority within 14 days ;" mping date in
accordance with 310 CMR 15.351. rvc
A. Facility Information
1. System Location:
ja__Cth
Address
No Andover
City/Town
2. System Owner:
Name
State Zip Code
Address (if differentrom location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
lions
3. Component: 111 Cesspool(s) 0/ Septic Tank 0 Tight Tank 0 Grease Trap
0 Other (describe):
4. Effluent Tee Filter present? II Yes Ef No If yes, was it cleaned? 0 Yes No
5. Observed condition of component pumped:
tO(f/
6. Sys_t„.„m! rrIped By:
Name
Steydrts-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
Signature of Receiving Facility (or attach facility receipt)
Date
Date
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