HomeMy WebLinkAboutSeptic Pumping Slip - 543 FOREST STREET 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 Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumpi
accordance with 310 CMR 15.351.
A. Facility Information
Important:
filling out formsWhen 1. System LocaPon: o",
on the computer,
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
2. System wn r:
rib
...........................
Name
rennn
.......... -------------_____
Address(if different from location)
_...._. w _,, ..,,...,Y.,_
Cit /Town State Zip Code
12 'A
Telephone Number
B. pumping Re66"f&__. 1
1. Date of Pumping -i 2 Quantity Pumped,,
D te / Gallons
3. Component: F1 Cesspool(s) 5eptic Tank El Tight Tank F-1 Grease Trap
F] Other(describe): ..........
4. Effluent Tee Filter present? E] Yes ❑ If
yes, was it cleaned? El Yes ❑ No
5. Observed condition of corponent pumped:
& Syste umped y: j
.................. Vehic're Li/ense-Number --_Stewart'
.. -a T _eptic 58 So. Kimball St., Bradford,MA
Company
M/P
Nam
SteIT
here
Contents W,
St,
B adford, M)
7. Lpeatio here contents were disposed:
0
20 So. Mil t,.LB�adforcl, MA
SiSib ire of Hauler Date
...........
Signature of Receiving Facility(or attach facility receipt) Date
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