HomeMy WebLinkAboutSeptic Pumping Slip - 975 FOREST STREET 5/5/2017Important: 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 fr:ithe.
date in
accordance with 310 CMR 15.351,
A. Facility Information
1. System Location:
isZ-Latrc
Address
No Andover
City/Town
2. System Owner:
State
.;\''.''.." . •
Zip Code
Naine
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
/3
Date
2. Quantity Pumped:
3. Component: L Cesspool(s) 1"Septic Tank
111 Other (describe):
4. Effluent Tee Filter present? El Yes 111 No
5. Observed condition of component pumped:
122
6. System Pumped By:
Nam
Q IA "7
IC; 0
Gallons
Lil Tight Tank Ili Grease Trap
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Si ture o auler
Signature of Receiving Facility (or attach facility receipt)
If yes, was it cleaned? 111 Yes El No
Vehicle License Number
)7
Date
Date
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