HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 5/7/2018 (3) Commonwealth of Massachusetts
City/Town of No. Andover, MA
_IVED
System Pumping Record
Form 4
u-1�n9
DEP has provided this form for use by local Boards of Health. Other formV "�i6d[)16idiihe
information must be substantially the same as that provided here. Before u 2g 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 35-1 W&I
key to move your Address
cursor-da not
A10
use the return MA
key. City/Town State Zip Code
Z System 0 ner:
"30V
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallon6
3. Component: F Cesspool(s) R Septic Tank El Tight Tank F Grease Trap
they(describe):
4. Effluent Tee Filter present? D Yes o If yes, was it cleaned? 7 Yes n No
5. Observed condition of component pumped:
6. Syster(ri-PUrAlrd By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bnqdford,M A
Company
7. Location where contents w -disposed:
20 Mill S� Bradfo MA
2
Si nature of Tate
Signature of Receiving Facility(or attach facility receipt) Date
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