HomeMy WebLinkAboutSeptic Pumping Slip - 51 LONG PASTURE ROAD 7/9/2018 � Commonwealth of Massachusetts m , ;,, ''��f�D
City/Town of No. Andover l:
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System Pumping Record
Form 4 004 U tvK' ti � I �
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 A dress
cursor-do not No. Andover MA 01945
use the return _. —. _ _ .._._.. ..............._._
key. City/Town State Zip'Code
r 2. System er (
Name .._. ...._._w.._._ ....._
rcrwn
.. _ _ ....
Address different rom location
Cityl-own State Zip Code
... _
Telephone Number
B. Pumping Record
w.
CG7
1. Date of Pumping 2. Quantity Pumped. Gallons
3. Component: ❑ Cesspool(s) 'Septic Tank [I Tight Tank ❑ Grease Trap
❑ Other(describe): _..._ .... ... ._..._._
4. Effluent Tee Filter present? ❑ Yes lu No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pu T
ed B
7Y
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
1
7. Location where contents were disposed:
20 So.
......._.._ Mill St., Brad, rd,,MA
...... ..
3
Signat tie of H uler Date
Signa ure of Receiving Facility(or attach facility receipt) Date
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