HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 9/21/2018 (7) Commonwealth of Massachusetts
City/Town of No. Andover a c
a a
w System Pumping Record
fi
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 34 ._ �.� ...... " _. _ ... _._......... ........ _._—._
key to move your Address
cursor-do not No. Andover MA 01845
use the return _.._....
key. City/Town State Zip Cade
2. System Owner:
tie
...._ _... _ .. ..
za
Name —. .
ret�n
Address(if crifferent from location)
_..._. __.......
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: .-.
Date Gallons
3. Comp hent: ❑ Cesspool(s) F-1SepticTank El Tight Tank ❑ Grease Trap
I +gym +,^"`
Other(describe): ./ , (_.._I_-_ ..Cfi?+J.._ .5 .... ................
4. Effluent Tee Filter present? ❑ Yes 00 If yes, was it cleaned? ❑ Yes ❑ Na
5. Observed condition of component pumped:
t
--- ....__.. ......._.. _..._w..
6. Systeumped B
VU
Name Vehicle License Number
Stewart's Septic 58 So. Kimb" St., Bradford,MA
.........
..............
Company
7. Location where contents were disposed:
2Q So. Mill St., Bradfor , A
_ _...
k4Lc
jSila—ture
a of Haule a Date
..........
of Receiving Facility(or attach facility receipt) Date
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