HomeMy WebLinkAbout- Septic Pumping Slip - 230 LACY STREET 9/21/2018 Commonwealth r~fR�Massachusetts
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System Pumping Record
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Form 4 . .'
DEP has provided this form for use by local Boards of Health. Other forms may be used, butthe
information must bgsubstantially the same amthat 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 31QCyNR15.351.
A. Facility Information
Important:When
filling 1. System Location:
on the computer,
use only the tab
key to move your Address
""= -""=` No, Andover01945
use the return
key. City/TownCity/TownState Zip Code
2. System Owner:
Name
Address(if different from location)
utyvown State Zip Code
____
Telephone Number
B. Pumping Record
1. Date ofPumping omm 3. Quantity Pumped: Gallons
3. Component: [l Cesspool(s) [-��-pticTank 0 Tight Tank [l Grease Trap
F] Other(describe):
4� Effluent Tee Filter present? M Yes E] No |fyes, was itcleaned? [l Yea [7 No
5. Observed condition ofcomponent pumped:
6. System Pumped By:
Name Vehicle License Number
Stewart's
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford MA
Gi800dumnfHauler Date
Signature ufReceiving Facility(or attach facility receipt) Date
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