HomeMy WebLinkAboutSeptic Pumping Slip - 67 SUNSET ROCK ROAD 6/7/2018 Commonwealth of Massachusetts 0
�
City/Town of No. Andover, MA
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. father 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 t
Important:When
filling out forms 1. System Location:
on the computer, IV
only the tab / Jif '. f 4 c
key to move your Address
cursor-do not ❑o r,elf MA '
use the return Cit !Town
key. Y State Zip Code
rae
2. System owner:
Name _......
ream
Address(if different from location)
Cityfrown State Zi C L
Telephone Number
B. Pumping Record
1. Date of Pumpingpate eeptfic
Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Tank ❑ Tight Tank ❑ Grease Trap
❑ other(describe):
4. Effluent Tee Filter present? ❑ Yes 100/
If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compon nt pumped:
_. ---------------
6.
------------6. Syst�etta�-Pftped By,:- `
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company 1
i
7. Location where contents were disposed: j
So. Mill St._Bf°adf rd MA
_ ------------
jSiature of Hauler pate
..-_........._ature of Receiving Facility(or attach facility receipt} Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1