HomeMy WebLinkAboutSeptic Pumping Slip - 66 SPRING HILL ROAD 7/9/2018 Commonwealth of Massachusetts � � ""
City/Town of No. Andover, MA
System Pumping Record TOWN jj� II ANDD n
Form 4
DBP has provided this form for use by local Boards of Health, Other forms may be used, but the j
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 I
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. f
I
A. Facility Information
Important:When
filling out forms 1. System Location: i"? 0 /
on the computer,
use onlythe tab ✓
key to move your Address
cursor-do not North Andover MA 01945
use the return _._._...___....
key. City/Town State Zip Code
2. System Owner:
VQ
AA
Name
reran
Address(if different from location)
................ __..__._._...__
City/Town State Zip Code
Telephone Number
B. Pumping Record
/ °
1. Date of Pumping Date W 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) peptic 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 Purged y:
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:'RIA
f
Signature of Fl uCer Date
._._..........._._._— ._m..-_..m __m....
Signature of Receiving Facility(or attach facility receipt) Date
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