HomeMy WebLinkAboutSeptic Pumping Slip - 20 ENGLISH CIRCLE 7/9/2018 Commonwealth of Massachusetts D
wl City/Town of No. Andover, MA
System Pumping Record
TOWN WF011 0Vr AN0
Form 4 NA 111 DUD/4"UMENT,,R
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 North Andover MA01945
use the return City/Town State .......... Zip Code
key.
2. System Owner:
reg 6—" o
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
0 '
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: El Cesspool(s) Septic Tank 0 Tight Tank El Grease Trap
❑ Other(describe): —-------------..........—------------------------------- ----------
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? E] Yes E] No
5. Observed condition of component pumped:
L
6. System Pumpe
C)
Name Vehicle License Number
Stewart's Septic_5.8 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
................. ....... ------
ignature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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