HomeMy WebLinkAboutSeptic Pumping Slip - 594 BOXFORD STREET 8/8/2018 Commonwealth of Massachusetts
City/Town of No. Andover, MA
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 ,amustUfitted to
the local Board of Health or other approving authority within 14 days from the pumfj"( , NM1
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 6" q ,
_ f .
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
reran
Address(if different from location)
City/Town
ty/Town State Zip Code
--------------
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: El Cesspool(s)
Septic Tank El Tight Tank 0 Grease Trap
❑ Other(describe): --------------
4. Effluent Tee Filter present? El Yes [ No If yes, was it cleaned? F-1 Yes Ej No
5. Observed condition of component pumped:
...............-
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
T. Location where contents were disposed:
20 So. Mill St., Bradford, MA
-----------------
S!Pa6�e4'oia�uler Date
---------------...............- ..............
Signature of Receiving Facility(or attach facility receipt) Date
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