HomeMy WebLinkAboutSeptic Pumping Slip - 115 CRICKET LANE 4/9/2018 Commonwealth of Massachusetts
City/Town of Forth Andover
System Pumping Record
Form 4 �� � ��� vk(,
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 your l
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. j
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 notJ> j MA_
use the return
key. Citylfown - State Zip Code Q -
2. System Own r:
,
Name
rerun
_ _._...
Address(if different from location)
City/Town - State Zip Code -
Telephone plumber
Pumping Record
1. bate of PumpingDate - 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 component pumped:
6. System Pumped By: / Ar0 t
Name Vehicle License Number
Stewark's Septic 5t3 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
-
i
Signature of—Hauler -"--- Date -
Signature of Receiving Facility(or attach facility receipt) Date
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