HomeMy WebLinkAboutSeptic Pumping Slip - 249 REA STREET 12/12/2017 CoMM',,un'wealth of Massachusetts 4y
UtWTown of Forth Andover
$ystem Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms 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:When
filling out forms . 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return Citylrown State Zip Code
Y
2:"'k
8�rstem Owner:
Name`. P
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date / 2. Quantity Pumped: Gallons
3. ComponeW C] Cesspool(s) V,,,Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑-tq If yes, was it cleaned? ❑ Yes R-No,..m
5. Observed condition of compo nen pumped:
6. Sys Pumped B :
N me 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
t5form4.doc•11/12 System Pumping Record•Page 1