HomeMy WebLinkAboutSeptic Pumping Slip - 187 OLD CART WAY 6/7/2018 'FCLMINI
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Commonwealth of Massachusetts
Cit /Town of No. Andover, MA 30� 0 "1701,
ovER
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,,fhe for� 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 31 O'CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your
Address
cursor-donot
use the return ---
.... 0 MA
key. City/Town State Zip Code
2. System Owner:
Name
reran
Address(if different from location)
City/Town State Zip Code
Telephone Nymber
B. Pumping Record
6-1)
1. Date of Pumping e— Quantity Pumped. 1L—
Date Gallons
3. Component: El Cesspool(s) Septic Tank M Tight Tank F-1 Grease Trap
El Other(describe):
4. Effluent Tee Filter present? El Yes F No If yes, was it cleaned? El Yes F-1 No
5. Observed condition of component pumped:
6. System Pumped By: / ��
Name Vehicle License Number
StewaT§
_Septic 58 So. Kimball St., Bradford,IVIA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt)-- -Date
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