HomeMy WebLinkAboutSeptic Pumping Slip - 54 LONG PASTURE ROAD 5/7/2018 Commonwealth of Massachusetts
W City/Town of No. Andover MA
System Pumping Record
Formi
DEP has provided this form for use by local Boards of Health. Other forms m418 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, G '
1 ..........
key to move your Address ......
use onlythe tab C�
cursor-do not , MA
use the return _ _....... ......_
key. City/Town State Zip Code
2. System Owner:
r� 0 5
Name
,euun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ' 2, Quantity Pumped: - —
d,., 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:
(L4f7%t l'I r-F'
Name Vehicle License Number
Stewarts Septic 58 So Kimball St., Bradford,MA
......................
f? ........._ ......__.... .....__
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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