HomeMy WebLinkAboutSeptic Pumping Slip - 82 PADDOCK LANE 6/7/2018 1 �a ,id"� w�� �u,,,�
Commonwealth of Massachusetts 'v
W City/Town of No. Andover, MA JON
2018
System Pumping Record
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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 the 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 farms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not _.._�� 1 Cdr') MA
use the return
Clt /Town
key. y State Zip Cade
2. System O ner:
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Name T
NA
Address(if different from location) _
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date - 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
i
5. Observed condition of component pumped:
B. System Pumped By:
t i
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradfard,MA
Company
i
?. Location where contents were disposed:
20 So. Mill St., Bradford, MA
Signature of Hauler pate
Signature of Recelving Facility(or attach facility receipt) Date
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