HomeMy WebLinkAboutSeptic Pumping Slip - 35 WILLOW RIDGE ROAD 12/12/2017 Com�alth of Massachusetts w„ W
�. Cityl`Torivn of Borth Andover s ,
System humping 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 y(
local Board of Health to determine the form they use. The System Pumping Record must be submitted
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:wheri'
fining out forms . 1. System Location:
on the computer, . �t -J�/ �
tAj
use only the tab
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2.*S'ystem Owner:
Name`
Address(K different from location)
City/Town State Zip Code
"telephone Number
B. Pumping Record
1. Date of Pumping4-e 2. Quantity Pumped: Gallons
3. Component:' ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componen�praped:
6. System Pu ped B)(.
� � ..
Name Vehicle icense Nu ber
Stewarts Septic 58 So Kimball St Bradford Ma
Company
I
7. Location where contents were disposed:
i
20 so rn st Bradford ma t
ignature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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