HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 5/1/2017 tom, Commonwealth of Massachusetts
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City/Town of NO ANDOVER
S
Rystem Pumping ecord
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.
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A. Facility Information EcoVED
Important:When
filling out forms 1. System Location-
on the computer,
use only the tab
. ...............
key to rnove your Address
cursor-do not No Andover
use the return
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
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City/Town State Zip Code
-----------
Telephone Number
------------- ...............
B. Pumping Record
,
1. Date of Pumping D_
Date52. Quantity Pumped:
rf
3. Component: ❑ I
Tank El Tight Tank F1 Grease Trap
,Other(describe): -------------------------
4. Effluent Tee Filter present? El Yes El No If yes, was it cleaned? n Yes El No
5, Observed'T ondition of component pumped:
.... .. ....... .... .... .............
6� 11P d By:
ame Vehicle' ........
J;t:e icense Number
-�a�Xirnball St Bradford Ma
...... ....... . ............
Company
7. Location where contents were disposed:
20somill st bradford ma
ignatUre of Hauler'7 DateI .......... .........—
ignature of Re
calving_Fac_i1ity_(or_attach facility receipt) Date
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