HomeMy WebLinkAbout- Septic Pumping Slip - 165 INGALLS STREET 9/21/2018 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:
rob
----�❑_ t� _......._....
---- -------
Name
retrun
............... —--------
Address(if different from location)
—-------------
State Zip Code
–---------
Telephone Number
B. Pumping Record
1. Date of Pumping
—�es ( �9
3-,:.IL 2 uantity Pumped:
Date Ga Ions
3. Component: El Cesspool(s) 8epfic Tank E] Tight Tank E] Grease Trap
❑ Other(describe): -—------- ...........
4. Effluent Tee Filter present? El Yes 0 ,N6 If yes, was it cleaned? El Yes r-1 No
V
5. Observed condition of component pumped:
6. Syst umped B
Na e Vehicle License Number
Stewart's S tic 58 So. Kimball St., Bradford,MA
'Company ---
7 -Location where contents were disposed:
20o. M' St,, Bradford, MA
...........–
..........
I fi' ture of uler D1
-Signature of Receiving'Facility(or attach facility receipt) Date
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