HomeMy WebLinkAboutSeptic Pumping Slip - 50 STANTON WAY 5/5/2017Commonwealth 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 thvim • ng date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms 1. System Location:
on the computer, AinTatl
use only the tab
key to move your Address
cursor - do not No Andover
use the return
key. City/Town
return
2. System 0 ner: ,
1
State Zip Code
Id 1 n
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
Date 7 2. Quantity Pumped:
Gallons
State Zip Code
Telephone Number
3. Component: 111 Cesspool(s) EL --Septic Tank LI Tight Tank D Grease Trap
fp Other (describe):
4. Effluent Tee Filter present? LIJ Yes 13--Ntr- If yes, was it cleaned? LI Yes D No
5. Observed condition of component pumped:
6. System Pu d 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 Date
Signature o eiving Facility (or attach facility receipt) Date
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