HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 9/21/2018 (3) 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. System Owner:
Name
inrn
..........
Address(if different from location)
................
City/Town State
ov+Zip Code
Telephone Number
B. Pumping Record
I. Date of Pumping DW- 2. Quantity Pumped: Gallons
3. Com onent: Ej Cesspool(s) F-1 Septi Tank/ R Tight Tank F-1 Grease Trap
Other(describe):
4. Effluent Tee Filter present? M Yes El No If yes, was it cleaned? El Yes El No
5, Observed condition of component pumped:
r)
6-9-: 'd _7 ...—- -...............................
6. S em PumpNyd- By
JOe Vehicle License Number
Stewart's Septic 58 So., imball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So, fIFS)., Bradford,fMA
—--------- -------................ -------
(40
Signature of a er— Date
Signature of Receiving Facility(or attach facility receipt) Date
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