HomeMy WebLinkAboutSeptic Pumping Slip - 250 ABBOTT STREET 5/10/2017Commonwealth 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 Rec4nust be submitted to
the local Board of Health or other approving authority within 14 days frqp date in
accordance with 310 CMR 15.351.
16
Ii k'Di-C4'VL
A. Facility Information
Important: When
filling out forms 1. System Location:
on the computer,
use only the tab 5C
key to move your Address
cursor - do not No Andover
use the return
key. City/Town
234117
2, System Qwner:
Name L.—X) "
State
Zip Code
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
2. Quantity Pumped:
D"a e
1S7C0
Gallons
3. Component: 111 Cesspool(s) I2(Septic Tank El Tight Tank D Grease Trap
El Other (describe):
4. Effluent Tee Filter present? Li Yes 111 No If yes, was it cleaned? Lil Yes Lil No
5. Observed cmition f component pumped:
LAW tk-t
6. S
Pumped By:
tewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
o mill st bradford ma
Vehicle License Number
nature of Hauler Date
Signature of Receiving Facility (or attach facility receipt) Date
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