HomeMy WebLinkAboutSeptic Pumping Slip - 43 VEST WAY 8/8/2018 Commonwealth of Massachusetts
City/Town of No. Andover, MA AW3 0 8 2018
System Pumping Record 'rOW�4 Of"NORTH ANDOVER
Form 4 &U]-1 D&�IMJMENI'
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, Ve e'l— Way x
use only the tab
key to move your Address
cursor-do not No. Andover MA 01945
use the return ...........
key. CityfTown 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 -2. Quantity Pumped:
Date Gallons
3. Component: El Cesspool(s) ZSeptic Tank Tight Tank Grease Trap
n Other(describe): ..........--------- .........
4. Effluent Tee Filter present? ❑ Yes 7 No If yes, was it cleaned? ❑ Yes E] No
5. Observed condition of component pumped:
.............
6. System_Pped By.
7el)
Name Vehicle License Number
Stewart's Septic 58 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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