HomeMy WebLinkAboutSeptic Pumping Slip - 122 OLYMPIC LANE 8/8/2018 Commonwealth of Massachusetts
City/Town of No. Andover
System Pumping Record
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 PumpingRecorq e submitted to
the local Board of Health or other approving authority within 14 days from t;;6Af$ate in
accordance with 310 CMR 16.351.
A. Facility Information N
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab /2-2_0 N)n a)I C (0(r)-e
key to move your Address
cursor-do not No. Andover MA 01945
use the return .......
key. City/Town Sta#e Zip Code
2. System Owner:
—-----------A-Y.r,m/ ......................
Name
.......... ..........
Address(if different from location)
—-------------
..........
City/Town State Zip Code
..........
Telephone Number
B. Pumping Record
1. Date of Pumping
2. Quantity Pumped, Gallons
Date
3. Component: ❑ Cesspool(s) P",Septic Tank F-1 Tight Tank F-1 Grease Trap
❑ Other(describe): ............
4. Effluent Tee Filter present? F-1 Yes E"o If yes, was it cleaned? ❑ Yes D—I"
5. Ob . �ne t meed:condition of com
6. System Pumped By:
0
..........
Name Vehicle License Number
Stewart's Septic 58 So, Kimball St., Bradford,MA
11..............
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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