HomeMy WebLinkAbout- Septic Pumping Slip - 260 SUMMER STREET 9/21/2018 Z4- Commonwealth of Massachusetts
City/Town of No. Andover, M
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,
on the computer,
--
use only the tab
key to move your -Address
cursor-do not
No. Andover MA 01945
use the return
key, City/Town State Zip Code
2. Systep Owner:
Y"I
Name
retwn
—---------- .......... ...................-
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 F-1 Tight Tank n Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Fj Yes 0]""No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. Sys ern Pumped By:
ame Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20So. Mi St., Bradford, MA
/
gj; —//-?..................
Sinat�ur of Hauler Date
-Signature ofReceiving—Facility—(or-atia"c-h'---facility-—receipt)— -Date
t5form4,doc-11112 System Pumping Record -Page 1 of 1