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HomeMy WebLinkAboutSeptic Pumping Slip - 201 CARLTON LANE 5/7/2018 Commonwealth of Massachusetts -r City/Town of No. Andover, MA � System PPumping � � � �� Pumping Record ' v 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 1.4 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 1A)/ / - / �-./. �.i.._......4., ,p,, key to move your Address cursor-do not / use the return J mt �' � MA key. City/Town State Zip Code 2. System Owner: rob Name _ .....__._._ rerun Address(if different from location) City/'Town State od -, Telephone Number B. Pumping Record 1 / / Gall 's ^ t r 1. Date of Pumping Date Quantity Pumped: l onss 3. Component: ❑ Cesspool(s) (F'�,,SepticTank ❑ Tight Tank ❑ Grease Trap © Other(describe): ___._. __.--- 4. Effluent Tee Filter present? © Ye(�' No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of comporAnt pumped: 6. Sysiprrf'Pump6 y: 1M � -- 7 . 1-616t .............. Nam Vehicle License Number Stewart's Septic 58 So, Kimball St., Bradford,MA Company 7. Location where contents were disposed: 2 So. Mi!-St,"Br dford, MA _ _ .......... ( S` nature of Haug Date \ r. —.._ _._ _ — _ _w Signature of Receiving Facility(or attach facility receipt) Date., t5form4.doc-11/12 System Pumping Record•Page 1 of 1