HomeMy WebLinkAboutSeptic Pumping Slip - 55 FARNUM STREET 8/8/2018 Commonwealth of Massachusetts RECEIVED
Cit /Town of No. Andover, M
AUG 0 U018
System Pumping Record TC)VM OF MNM1 MDOVER
Form 4 -:AL11�NiPIR114 04 r
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.,,l 5.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the comp ,
91
,P-.
use only the tabuter
key to move your Address
cursor-do not North AndoverMA 01945
use the return ------------
key. City/Town State Zip Code
2. System Owner:
Name
Address if different from location)
............ ...................
City/Town State Zip Code
..................................
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons_-- ..................
3. Component: El Cesspool(s) Septic Tank , El Tight Tank ❑ Grease Trap
Other(describe): ..........
4. Effluent Tee Filter present? M Yes No If yes, was it cleaned? Fj Yes El No
5. Observed condition of component pumped:
6 System Pumped By:
--
...........
----------
—amr e Vehicle License Number
Stewart's Septic 58 So. Kimball 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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