HomeMy WebLinkAbout- Septic Pumping Slip - 1234 SALEM 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 LocaPon:
on the computer,
use only the tab /
ri�3 ❑ Zz
Ad
key to move your s
cursor-do not No. Andover MA 01945
use the return
key. City/Town State Zip Code
Z System
er:
Nam
—---------__
Address(if different from I tcation)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2, Quantity Pumped:
Dafe G61lons
3. Component: ❑ Cesspool(s) [��eptic Tank ❑ Tight Tank F-1 Grease Trap
M Other(describe): ------- .
4. Effluent Tee Filter present? [] Yes - If yes, was it cleaned? E] Yes E] No
--
5. Observed condition of component pumped:
..........
6. Sy te�' amps y:
Ce
A --------
N;Yme
---
Vehicle License Number
Stewart' eptiq 58 So. Kimball St., Bradford MA
Company
7-1ecation.where contents were disposed:
"k
120S�p. Mill S , Bradford, MA
.........................
Sign re,❑fffaule't,�, Da
p7v5
Signature of Receiving Facility(or attach facility receipt) Date
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