HomeMy WebLinkAboutSeptic Pumping Slip - 75 TANGLEWOOD LANE 8/8/2018 Tz"7,-
L\ Commonwealth of Massachusetts
City/Town of No. Andover, MA
v'z
System Pumping Record T0 \N11 0r,
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 date in
accordance with 310 CMR 15,351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
I CR
use only the tab Ak--
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 V
rertan
..................... . .......
Address(if different from location)
City/Town State Zip Code
—---------—
Telephone Number
B. Pumping Record T 156
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ElSeptic Tank M Tight Tank El Grease Trap
El Other(describe): ------------------
4. Effluent Tee Filter present? R Yes Fj No If yes, was it cleaned? F-1 Yes E] No
5. Observed condition of component pumped:
--------------------------
6. System Pumped By,
A41
.................. ...........
Name Vehicle License Number
Stewart's Septic 58 So. Kimba St. Bradford,MA
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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