HomeMy WebLinkAboutSeptic Pumping Slip - 51 STANTON WAY 5/5/2017Important: W hen
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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 from the pumpin e in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Loca) ion:
__01____
Address
No Andover
City/Town
2. Sy t(em Owner:
Name
State
Zip Code
Address (if different from location)
CitylTown
State Zip Code
Telephone Number
B. Pumping Record
1,
Date of Pumping
3. Component:
Date
2. Quantity Pumped:
LI Cesspool(s) a.-8-eptic Tank 1:1 Tight Tank
Lil Other (describe):
/57)
Gallons
LI Grease Trap
4. Effluent Tee Filter present? 111 Yes Er.gO
5. Observed condition of component pumped:
If yes, was it cleaned? 1=I Yes 111 No
6. System Pumped By'
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
Signature of R acility (or attach facility receipt)
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