HomeMy WebLinkAboutSeptic Pumping Slip - 356 RALEIGH TAVERN LANE 5/7/2018 Commonwealth of Massachusetts
r City/Town of No. Andover, MA
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be 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
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use onlythe tab
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key to move your Address. l
cursor-do notIj MA
use the return
key. City/Town State Zip Code
2. System Owner:
"I tt Gf �..... .G � ....
Name
tartan
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dake- — Gallons
2. Quantity Pumped: ---._-
Da
3. Component: ❑ Cesspool(s) °d 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:
c:-
. .....
6. System Pumped By: /
Name Vehicle License Number
Stewart's Septic 58 So..Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
i
20 So. Mill St., Bradford, MA
Signature of Hauler Date
Signature of Receiving F=acility(or attach facility receipt) Date
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