HomeMy WebLinkAboutSeptic Pumping Slip - 479 LACY STREET 6/7/2018 Commonwealth of Massachusettswr
City/Town of No. Andover MA
System Pumping Record
Form 4 "������ �l()p ����i�iAMER
i IL ALw Lek V Lb L''i i�'w..IL 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 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
filling out forms 1. System Location:
on the use only he tab
key to move your Address t u
cursor- not we) Aa V ,,1 MA
use the return
,urn —._
key. CityfTown State Zip Code
r� 2. System/}Owner:
Name
RYtiR
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) ® Sep Ict Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pum a By: _
Name Vehicle License Number
- - -- -
Stewart's Septic 58 So. Kimball St. Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St.., ad ard, A
17
Signature of Haul Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record-Page 1 of 1