HomeMy WebLinkAboutSeptic Pumping Slip - 10 HAWKINS LANE 2/7/2018 C;am,m,'fO wealth of Massachusetts
CltyfTow' n' of Forth Andover
ystem Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
'{ nformation must be substantially the same as that provided here. Before using this form, check With y
thel Board of
locaal Board of Health oro her apprh to determine the oving ngrm they use. The authority within 14 days frostem m he pumd must ping g date inubmittec
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out formi 1. System location:
on the computer, ff f
use only the tab 16 G� l l 1'1`s /0 0 C
key to move your Address r
cursor-do not,
use the return CitylTor�m
key. State Zip Code
2:"' S�stem 'Owner:
�,,
1Varnd';
r �
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
I. Date of Pumping Date 2. Quantity Pumped: Gallons
3. C6mponeiit4 ❑ 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 component pumped:
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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