HomeMy WebLinkAboutSeptic Pumping Slip - 160 COLONIAL AVENUE 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 from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
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1. System Location:
ta_Cd_OM
Address
No Andover
City/Town
2. System wcier:
Name
State
Zip Code
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
!SQO
Gallons
3. Component: LI Cesspool(s) IdSeptic Tank II Tight Tank D Grease Trap
LJ Other (describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? 1111 Yes 111 No
5. Observed condition of component pumped:
od
Date
2. Quantity Pumped:
6. Sytem Pumped By:
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
Vehicle License Number
7. Location where contents were disposed:
20 so mill 1t bradford ma
nature Hauler Date
Signature of Receiving Facility (or attach facility receipt) Date
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