HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 10/23/2017 (","PVx
dlo' rJ i"cr�iin�ealth of Massachusetts
dtylT'own of Noah Andover ���.d
ysterrt Pumping Record TOM
ljEgE jw.j[,lc PARTI IST
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
local Board of Health to determine the form they use.The System Pumping Record must be submitt�
-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:W heti
flaring out farm§ 1. System Location:
on the computer, ; µ "
use only the tab 5-1 AAL06LL -
key to move your Address
cursor-, do not
use the return Z C'dyrrown State 4 Zip Code
key. a
2.� Smystem Own �
• Name`:
-
Address(W different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping record
1. Date of Pumping pate ' 2. Quantity Pumped; Gallons
3. Component:• ❑ Cesspool(s) ,Septic Tank [ Tight Tank ❑ Grease Traa
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pump4l,
b
6. System Pumped By:
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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