HomeMy WebLinkAboutSeptic Pumping Slip - 62 WILLOW RIDGE ROAD 5/7/2018 Commonwealth of Massachusetts
City/Town of No. Andover. MA ❑ °
° System Pumping Record a �
Form 4w � i �
DEP has provided this form for use by local Boards of Health. Other forms may bek6 d, 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 fori 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 t
Important:When
filling out forms 1. System Location:
on the computer, / 7 f
use only the tab r G V ❑64,E (C /�
key to move your Address
cursor-da not Allo A p oLo iz,-eli' MA
use the return City/Town State — Zi Code
key. p
2. System Owner:
reb A-
Name _....
rerun
Address(if different from location) _
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumpingo e � - 2. Quantity Pumped: Gallon
3. Component: ❑ Cesspool(s) El,-Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _ _.....
4, Effluent Tee Filter present? El Yes [IN
o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pump
6. System P mped By:
Name t Vehicle License Number
Stewart's Se tp is 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., BrpdM, MA
n
Signature Hauler Date 3
Signature of Receiving Facility(or attach facility receipt) [late
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