HomeMy WebLinkAboutSeptic Pumping Slip - 1850-1852 SALEM STREET 6/7/2018 Commonwealth of Massachusetts D
City/Town of No. Andover, MA
System Pumping Record
Form 4 1 C04 )5,
Kllx'k�3 V�
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
filling out forms 1. System Location:
on the computer,
use only the tab .......
key to move your Address
cursor-do not
use the return ............... MA
key. City/Town State Zip Code
2. System Owner:
x
Name
renrn
-----------
Address(if different from location)
...................
City/Town StateZip co
51
Telephone Number
B. Pumping Record
1. Date of Pumping Quantity Pumped: (9
Date Gallons
3. Component: ❑ Cesspool(s) c eptic Tank ❑ Tight Tank Ej Grease Trap
El Other(describe):
4, Effluent Tee Filter present? [] Yes 0 If yqp, was it cleaned? F-1 Yes F-1 No
5. Observed condition of�o ponent p �/._
d
trme"
. ......... ---------------- —---------
6. SystefnPumpeo-b)r
/V1
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
2P So. Mill St., a
Prdfo,d, MA
a
a
.. ....................................................
J& nature of Hauler"." Date"
ignature of Receiving Facility(or attach facility receipt) Date
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