HomeMy WebLinkAboutSeptic Pumping Slip - 182 RALEIGH TAVERN LANE 2/7/2018 yy i'M
Co"MOMWealth of Massachusetts
lfCity/ToVvn* of forth Andover
❑stem Pumping 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 submitkec
-the local Board of Health or other approving authority within 14 days from the pumping date in
a �� � 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'
usethe return CitylTown .
key. State Zip Code
2* S�rstem Owner:
Name`-
Address(if different from location)
Cttyfrown State Zip Code
Telephone Number
B. PumplEng Record
1. Date of PumpingDate 2. Quantity Pumped: Gallons
3. Components' ❑ Cesspool(s) a 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 component pumped:
6. System Pumped,By "°°-. .
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
I
7. Location where contents were disposed:
20 so mill st bradford me
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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