HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 8/8/2018 f
Commonwealth of Massachusetts
- -= City/Town of No. Andover
mm .
W System Pumping Record
G. .. ; Form 4
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 da t
accordance with 310 CMR 15.351.
A. Facility Information __......................_... � �� ��
filling When
g out forms 1, System Location: Esu
on the computer, � �°'
use only the tabes / /�`J7µ
key to move your Address
cursor-do not No. Andover MA 01945
use the return
key. City/Town State Zip Code
2. System Owner:
tab
Name ......... .........__
renrn
Address(if different from location)
__..._,._,__ _... ...._..._
..................... _... ...
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat 2. Quantity Pumped: 915c�
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank [9—Grease Trap t
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
_....._
t
6. System Pumped By:
Name / Vehicle License Number
Stewart's-Se ic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So, Mill St., Bradford, MA
i
Signature of Hauler Date
_.... - . ..
_.................__
Signature of Receiving Facility(or attach facility receipt) Date
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