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HomeMy WebLinkAboutSeptic Pumping Slip - 356 REA STREET 6/7/2018 Commonwealth of Massachusetts City/Town of No. Andover, MA ,I . System Pumping Record Form 4 tl W4f b1 �� 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 fore 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 tilling out forms 1. System Location: on the computer, .. use only the tab !5 > /! key to moue your Address cursor-do not eld-0 o ? MA . use the return Cit /Town key, Y State Zip Code t� M1 � 2. System Owner: Name —� return Address(if different from location) Cityfrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumpingpate 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap El Other(describe): 4. Effluent Tee Filter present? © Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: d�1�3 Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. Mill St., Bradford, MA Signature of Hauler Date 1 Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1