HomeMy WebLinkAboutSeptic Pumping Slip - 114 SPRING HILL ROAD 5/7/2018 Commonwealth of Massachusetts RECEIVED
City/Town of No. Andover, MA
11 Ay ("I Z'0 18
System Pumping Record -rOWN or.WR714 0i[)okR
Form 4 U11"AFUMEW
wM
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
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.
..............................
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, [_2
use only the tab . ..... ------ ...... ........................
key to move your Address
cursor-do not
use the return - N_v_ MA ——-----------------
key. City/Town State Zip Code
2. System Ownerab r�,
0 bo,
...............
Name
Address(if different from location)
City/Town Stater Zip Code
-----------
Telephone Number
B. Pumping Record
1, Date of Pumping - 'l Date .1 2. Quantity Pumped: Gallons
3. Component: F] Cesspool(s) `Septic Tank El Tight Tank El Grease Trap
F-1 Other(describe): ...............................................................................
4. Effluent Tee Filter present? El YesEl No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
G. System Pumped By: 6M
Name Vehicle License Number
.Stewart's 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 of 1