HomeMy WebLinkAboutSeptic Pumping Slip - 30 VEST WAY 5/7/2018 Commonwealth of Massachusetts
w r City/Town of No. Andover, MA
System Pumping Record
Form 4n
DEP has provided this form for use by local Boards of Health. Other forms may*',�" t the
information must be substantially the same as that provided here. Before using thisfiorm, 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 _ ... _ V v. .y...
key to move your Address _... ... .-- __..._
cursor-do not ❑o Aqv-d c, �, 4?, i MA
use the return _... ......_ _......�..
key. City/Town State- Zip Code
2. System Owner:
teb
__..._. P
Name _ ..
reran
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
�,. .. ,. ❑
1. Date of Pumping Date 2�,Quantity Pumped: —
G11 a11 ll1.ons
3. Component: ❑ Cesspool(s) ['Sep Tank_ ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ___._.........__. ._.__._........__ . ......._-----------_...__
4. Effluent Tee Filter resent? Yes `�
p ❑ [�" No If yes, was it cleaned? F-1 Yes ❑ No
5. Observed condition of component pumped:
6. S s erxa.Pumped By:
❑ " W µ -._ / _..
Name Vehicle License Number
Stewart's Septic 58 So, Kimball St., Bradford,MA
Company
7. Location where contents werp.d'rsposed:
20 0 fait St., Bradfor ,,- A
.. -_ _.— .......
Signature of H ler Date
—. —. — —..- ----------------.
Signature of Receiving Facility(or attach facility receipt) Date
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