HomeMy WebLinkAboutSeptic Pumping Slip - 30 SHERWOOD DRIVE 7/9/2018 Commonwealth of Massachusetts F��,,r::,CEIVED
City/Town of No. Andover, MA
JUL
Systern Pumping Record
Tom OF NOMiA ANDOVER
PA
fU'MEW
Form 4 HEALTH DL
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 Roy .-rd of Health to determine the 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. Fneflity Information
Important:When
filling Out forms 1. SyStEdr) Location:
on the computer,
use only the tab
key to move your Address
cursor-do not Nortl i Andover MA
use the return Cityf'['own State ........ Zip Code
key,
2. System Owner:
rab
M o
——-----__-
Name
--at
ertan
Address(if different from location)
-------------
City/Town State Zip Code
Telephone Number
zinnping Record
5 CYD
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) eptic Tank El Tight Tank El Grease Trap
El Other(describe): ........
4. Effluent Tee Filter present? El Yes o If yes, was it cleaned? F-1 Yes R No
5. 01,')served condition of compone pumped:
........................................
6. System Pump
(Y/
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
company
7. Location where contents wered' ed:
2" _RT'Mill t. Bradford
S 11- r
ig ,tu tu T a e Date
...........
SignaWic,of Receiving Facility(or attach facility receipt) Date
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