HomeMy WebLinkAboutSeptic Pumping Slip - 136 STONECLEAVE ROAD 7/9/2018 Commonwealth of Massachusetts � d i
City/Town of No. Andover �� `
Y p�
System Pumping Record 'Afl, V018
Form 4
TI,i V-[0ZU II i ANDOVER
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information muse 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
fining out formsSystem Lacatlon �
on the computer, ° a
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. SystemryOwner:
Name
�etr�n
...........................................
Address(if different from location)
..-..-..-____ _.__ __. ........ _.._.. .. .........._._. .....
City ./Town State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping Data '( •�
2 quantity Pumped: Gallori ......_.._..........._
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank C] Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 6No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. Srte .,;Pumped By;
_........ ----__ _..__.....
Name Vehicle License Number
Stewart's Septic 58 So Kimball St., Bradford,MA
Company
7. Location where contents werp,,dosed:
20.5 ._Mill St., Bradfor "A
i nature of Hau r Date
_.. ....._.... ..... _ .... __.._ _ ...... ..._ .......... _.
Signature of Re giving Facility(or attach facility receipt) Date
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