HomeMy WebLinkAboutSeptic Pumping Slip - 745 FOSTER STREET 5/7/2018 Commonwealth of Massachusetts
City/Town of No. Andover, M U""".
System Pumping Record mm 07 1110W)
Form 4
[Owq(fi' 1"8
DEP has provided this form for use by local Boards of Health. Other forms maw"sri 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,
use only the tab 4-5
key to move your AddrNS
cursor-do not MA
use the return ................
d
key. City[Town State Zip Code
2. System,Owner:
VQ AL
Nanhe'
Address(if different from location)
–------------------.............................
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping V// lo—........... 2 uantity Pumped:
Date I Gals ns
3. Component: F] Cesspool(s) M.-Septic Tank El Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? F-1 Yes �,Ao If yes, was it cleaned? 0 Yes ❑ No
5. Observed condition of omponent pumped:
............. ------------------------
6. Systr
m By:
�- I-anz, -------------- .. .......
Name Vehicle License Number
Stewart tic 58 So. Kimball St., Bradford,MA
........... p
Company
7. Location where contents were disposed:
20So.4MiBradford, MA
Sig!��tf6 o0au're-r D
Signature of Receiving Facility(or attach facility receipt) Date
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