HomeMy WebLinkAbout- Septic Pumping Slip - 9/21/2018 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 liollr�m' s 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,
use only the tab Od
............. --_._....`µ..J__._- ---------- ..........
key to move your Address
cursor-do not No. Andover MA 01945
use the return .......... .....................
key. City/Town State Zip Code
2. System 0
reb
--- ——-------------- ......................------------------------------------------
Name
-- ------------
Address(if different from location)
City/Town State Zip Co '
de A
0 3 S
Telephone Number
B. Pumping Record
1. Date of Pumping
2. Quantity Pumped:
Date Gallons
3. Component: M Cesspool(s) Cd- SepticTank El Tight Tank n Grease Trap
—---------
M Other(describe):
4. Effluent Tee Filter present? F-1 Yeslj[" No If yes, was it cleaned? F-1 Yes El No
5. Observed condition of component pumped:
---------- m.r C'
6. ped
(P
S
...................
ry Vehicle License Number
Stewart's Septic 58 So. Kimbal, t., Bradford,MA
Company
7. Location where contents were disposed:
0 So. Mill St" dford, MA
..
............................ ------------
d
C.)
ibnature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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