HomeMy WebLinkAboutSeptic Pumping Slip - 17 CROSSBOW LANE 7/9/2018 Commonwealth of Massachusetts RECEIVED
9
City/Town of No. Andover, MA JUL
a _ a System Pumping Record TOWN OF NM,11.1 ANDOVrii,
Form 4 11EA I DEPMUMEW
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 fori 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 910 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, ref /,
use only the tab r ( ` W-S-S W � .,4.,').,,
key to move your Address
cursor-do not G
use the return /Town
key. Cit y State Zip Code
2. System Owner:
Name
tenon _......... _... _.........
Address(if different from location)
_
City/Town State w------
Zip Code
Telephone Number
B. Pumping Record _.
--6 ,W f C*
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank El 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 P p�edBy.
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford MA
Company
7. Location where contteent!"ere-d•i used:
20 So. Mill St., f9dford ,771
16
AF
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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