HomeMy WebLinkAboutSeptic Pumping Slip - 9 TURTLE LANE 5/15/2017Important: 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 purrg date in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
aul.--tc., co
Address
No Andover
City/Town State Zip Code
2. System 0 ner:
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date 2. Quantity Pumped:
3. Component: [1] Cesspool(s)
LI Other (describe):
4. Effluent Tee Filter present? El Yes IIT—N-o
//3-Z)6)
Gallons
R—S-61-3tic Tank El Tight Tank El Grease Trap
If yes, was it cleaned? Lil Yes LI No
5. Observed condition of component pumped:
g e4cx.ok
6. System Pumjed By:
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler
Signature of R
-ra-aity (or attach facility receipt)
Vehicle License Number
Date
Date
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