HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 7/9/2018 (5) Commonwealth of Massachusetts RECEIVED
City/Town of No. Andover 9201B
System Pumping Record11 MDOVER
JOWN 0F
MUDIARWENT
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 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,
use only the tab
key to move your Address
cursor-do not No. Andover MA 01945
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
Name
raaan
.....................
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: F-1 Cesspool(s) r_1 Septic Tank El Tight Tank ErGrease Trap
r_1 Other(describe): I.........................
4. Effluent Tee Filter present? [:1 YesE] No If yes, was it cleaned? El Yes El No
5. Observed condition of component pumped:
"/v,
...........---------- ........ ----— -- -----------
6. System Pumped 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., Bradford, MA
.................................................................___................—----------
... ...............
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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