HomeMy WebLinkAboutSeptic Pumping Slip - 26 LONG PASTURE ROAD 6/7/2018 Commonwealth of Massachusetts C�GIVE
City/Town of No. Andover, MA
System Pumping Record JUN
a 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 forms 1. System Location:
on the computer, .. ,
use only the tab 11 � f
6 1,e)&
key to move your Addr s
cursor-do not MA
key the return Cityrrown State Zip Code
Y
2. System OOV�n.,
Name
rerun
Address(if different from location)
City/Town State Zip Cody
Telephone Number -
B. Pumping Record
1. Date of Pumping / -- 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Aseptic Tank F] Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 19 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System P'W:R ed
Name Vehicle License Number _
Stewarf's S# tic 58 So. Kimball St., Bradford,MA
Company
I
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record-Page 1 of 1