HomeMy WebLinkAboutSeptic Pumping Slip - 1515 SALEM STREET 5/7/2018 Commonwealth of Massachusetts
a City/Town of No. Andover, MA ,
System Pumping Recordrvk H
Form 4 '°
i � V ,. i
DEP has provided this form for use by local Boards of Health. Other forms may I�'sed, but the
information must be substantially the same as that provided here, Before using this form, check with your t
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. 1
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, /5-/6-
5//C S61
use only the tab .J
key to move your Address -
cursor-do not NO i7�f7 ( ��r� MA
use the return
key. City/Town State Zip Code
2. System Owner:
Name
renrn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Ballo -
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 com lent pumped:
6, to Pumped By: (�
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contentswere 'sposed:
o.
S 'll St., Bradford
"✓'w C „
Signature of aule,s Date
Signature of Receiving Facility(or attach facility receipt) Date
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