HomeMy WebLinkAboutSeptic Pumping Slip - 1077 OSGOOD STREET 8/8/2018 Commonwealth r,fMassachusetts
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No. Andover, MA
System Pumping �� ��
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Form 4
DEP has provided this form for use by local Boards ofHealth. 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 ofHealth to determine the form they The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pu c 51D
accordance with 310 CIVIR 15.351. jrf
A. Facility Information
Important:When
filling out forms 1. System Location: lcll�p�"��°-
onthe computer,
use only the tab /0-7
key tomove your Address �
uumo/'do not No. Andover
MA 01945
use the return
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Tmmo 8xom Zip Code
Telephone Number
B. Pumping Record
1. Date ofPumping Date ' 2. Quantity Pumped: 16
ona
3. Component: El Cesspool(s) [l Septic Tank F-1 Tight Tank seTnap
|l Other(describe):
4. Effluent Tee Filter present? [| Yee El No |fyes, was itcleaned? 0 Yes [l No
5. Observed condition of component pumped:
O. System Pumped B
Name Vehicle License Number
Stewart's 3 i 58 So. Ki b�U| B Bradford,
Company
7. Location where contents were disposed:
20 So. M||| St., Bradford, MA
@gnomnanfHauler Date
GignotunaofReceiving Facility(or attach facility receipt) Dooa
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