HomeMy WebLinkAboutSeptic Pumping Slip - 162 STONECLEAVE ROAD 7/9/2018 Commonwealth of Massachusetts
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City/Town of No. Andover
System Pumping Record �� ��. �� m. 0
Form 4
10
Wht lel l
DEP 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
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 1(2d L L ¢, .............._
key to move your Address
cursor-do not No. Andover MA 01945
use the return ___. _._-.
key. City/Town State Zip Code
2. System Owner:
Name
renrn
.....................
Address(if different from location)
City/Town State Zip Code
_....... .......... ----
Telephone Number
B. Pumping Record
1. Date of Pumping ' �a 2. Quantity Pumped: ---- -
Date .- Gallons
3. Component: ❑ Cesspool(s) [r ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - -
4. Effluent Tee Filter present? ❑ Yes
If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compane pumped:
6. System Pumped By: ❑ a l
_- 1
Name vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
0" '—Mi St., Brad ,-. A'--- �
il❑._. �— --- ._..._.
Signature of ul Date
.... ....
......... _
Signature of Receiving Facility(or attach facility receipt) Date
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