HomeMy WebLinkAbout- Septic Pumping Slip - 215 RALEIGH TAVERN LANE 9/21/2018 �
Commonwealth rfMassachusetts
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| x��/ u�mx| | ^�/ No. Andover, MA
������� Pumping Record
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Form 4
DEP has provided this form for use by local Boards CfHealth. Other forms may be used, but the
information must be substantially the same aathat 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 31UCN1R15.35i.
A. Facility Unforrna*^on
fillingant:When
� out forms 1. System Location:
on the computer,
key to move your Address
""'°~' -""'"^ No. Andover MA 01945
use the return
City/Town State Zip Code
key.
2. System Owner:
Name
Addromo(if different from location)
Qty/Town State Zip Code
Telephone Number
B. Pumping
Record
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1. Oahe of Pumping2. Quantity Pumped:
Date Gallons
3. Component: Cesspool(s) eptic,Tank n Tight Tank E] Grease Trap
r-1 Other(describe):
4. Effluent Tee Filter present? [j YV'Alo |fyes, was |tcleaned? [] Yee [] No
5. Observed condition ofcomponent pu ped:
G. G m Pump
Name" - � ~ Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location h disposed:
Si nature of Haule r Date
9 Facility(or attach facility receipt) Date
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