HomeMy WebLinkAbout- Septic Pumping Slip - 54 CEDAR LANE 9/21/2018 a-
o Commonwealth of Massachusetts
_ =
City/Town of No. Andover, MA
System Pumping Record
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Form 4
DBP has provided this form for use by local Boards of Health. Other farms may be used, but the
information must be substantially the same as that provided here. Before using this farm, 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. r
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab r� :.❑' ❑w.G-❑
......... .................. _ ._._._ _....
key to move your Address
cursor-do not No, Andover MA 01945
use the return
key. City/Town State Zip Cade
2. System Owner:
_. ........................
Name _......_..._
�enrn
Address(if different from location)
City/Town State Zip Code
-
Telephone Number
B. Pumping Record
..._ ,:
4
1. Date of Pumping ............... 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): – _........._.__._
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes 6 o
5. Observed condition of/c`o�mponentumped:
6. S
tem Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA c
- ._...
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
__... ---
.....--------— .._...........__..... ........
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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