HomeMy WebLinkAbout- Septic Pumping Slip - 265 HAY MEADOW ROAD 9/21/2018 Commonwealth of Massachusetts
City/Town of No. Andover MAS13
System Pumping Record
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:
mthe ove t our Add fL� °f'!G L?i�(?_,u Gid r l/ 12c
on the computer,
use o Q„
Y Y Address
cursor-do not No. Andover MA 01945
use the return __......_ _.
key. City/Town State Zip Code
2. System Owner:
tab �
Name ._._.
....�. ..._..._ _ ......._ ___.._._.__... .................._.—
Address(if different from location)
_.... _. ........ ...... .......... _..
City/Town State Zip Code
Telephone Number
B. Pumping Record fi ❑❑❑
1. Date of Pumping — Ga2. Quantity Pumped: ____
Date llons
3. Component: ❑ Cesspool(s) V Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes o
5. Observed condition of co pane pumped:
M .._....._... .. _...
6. System Pumped y:
N ' .
a
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 j
I
1
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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