HomeMy WebLinkAboutSeptic Pumping Slip - 40 STERLING LANE 11/16/2017 f4
r Commonwealth of MassachusettsRECEIVE
City/Town of Borth Andover �,i� �;� A, ` 0 W
System Pumping Record T , �lOF,t )R1'H MOVER
Form 4. HF iALXH lei PART iw W
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 J
F
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
Important:When
filling out forms 1. System Location-
on the computer, 4 /
use only the tab ��
key to move your Address
cursor-do not North Andover
use the return Cityf town State Zip Code
key.
2. System Owner:
( � -
Mame
Address(if different from location)
City[rown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat ...... _ 2• Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) F?Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — - —
4. Effluent Tee Filter present? ❑ Yes Ej No If yes, was it cleaned? ❑ Yes ❑ No
5. Observe condition of component pumped:
6Ps
Pumped By:
Vehicle License Number
Septi 58 So Kimball St Bradford Ma—
Company
T. Location where contents were disposed:
120 mill st bradford ma
gnature of er Date
Signature of eiving Facility(or attach facility receipt) Date _
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