HomeMy WebLinkAboutSeptic Pumping Slip - 940 FOREST STREET 1/16/2018 x A:: ljr
Comm,OTnwealth of Massachusetts
City/Town' of Noah Andover
$ystem Pumping Record
F6rm 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 yr "
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 farms . 1. System Location*
on the computer, C "�
use only the tab
key to move your Address
cursor-do not
use the return /Town
G'
key. �` -9't ate Zip Code
gystem wner"
ray
Name':
Address(if different from location)
CityR own State d Zlp4`o71—
T4epon e Number
B. Pumping Record
1. Date of Pumping Date f Quantity Pumped: x
Gallons
3. Components E1Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes . o If yes, was it cleaned? 0 Yes ❑ No
5. Observed conditionrrrtao en umped:
/d
6. Sy..stPumped By
to i�l 3
ame Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where cote were disposed:
2 so mill st bradford m .. --•.-
nature of Hauler pa{e
Signature of Receiving Facility(or attach facility receipt) Date
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