HomeMy WebLinkAboutSeptic Pumping Slip - 5 CROSSBOW LANE 6/7/2018 IL
Commonwealth of Massachusetts
City/Town of No. Andover, MA
I System Pumping Record
Form 4
V0,
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 determinelfhe fora 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 Locaticn:
on the computer, '5 d"s,�-
use only the tab
key to move your Address
No
cursor-do not 511A-ell MA
use the return
key. City/Town State Zip Code
2. System Owner:
Name
renin 1
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping2. Quantity Pumped:
Date Gallons
3. Component: n Cesspool(s) ER'Septic Tank Tight Tank n Grease Trap
7 Other(describe):
4. Effluent Tee Filterpresent? F 11 Yes ❑ No If yes, was it cleaned? 2--Ve�s Ej No
5. Observed condition of component pumped:
6. System P ed By:
Name Vehicle License Number
StewaqA Septic 58 So Kimball St., Bjqdfqrd MA
Company
7. Location where contents were disposed:
20 So. Mill St., Brad
............
r
:4 -
Signature,of Haut r Date
-Signature"o—fReceiving Facility(or attach facility receipt) Date
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