HomeMy WebLinkAboutSeptic Pumping Slip - 250 ABBOTT STREET 6/7/2018 Commonwealth of Massachusetts
- . City/Town of No. Andover, MA 'Aflvl O 7 2015
a System Pumping Record of N"11)WE
Form 4
v
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 determinerthe 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
Important:When
filling out forms 1. System Location:
on the computer, t
use only the tab -d,5-0 Ab& (
key to move your Address
cursor-do not No Vel MA -
use the return City/Town state Zip p Code
2. System owner:
❑ 6 l'
Name _
�snrn
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping nate 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) �"eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ other(describe): ----
4. Effluent Tee Filter present? ❑ YesNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
1
36 l
6. System Pum
f
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
I
Signature of Hauler Clate
Signature of Receiving Facility(or attach facility receipt) Date
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