HomeMy WebLinkAbout- Septic Pumping Slip - 2189 SALEM STREET 9/21/2018 �d Commonwealth of Massachusetts
City/Town of No. Andover 1 9p01N
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
Vocal 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 fi
accordance with 310 CMR 15.351. r
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use
key o move your Address
cursor-do not No. Andover MA 01845
use the return —_......w _..__.._._.... ...-_..
key. City/Town State Zip Code
r� 2. System Owner,
Name
rer�rr
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping . ..... 2. Quantity Pumped: ---
Date Gallons
3. Component: F-1Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
C] Other(describe): .......-_.... ---- .....
4, Effluent Tee Filter present? F-1YesNo If yes, was it cleaned? ❑ Yes ❑ No
17
5. Observed condition of compo nt pumpe .
6. S em Pum
Name Vehicle License Number
Stewart's Septic 8 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20S it t., Br ford, MA
ur+ l
Signature of Hau br Date
...... .
Signature of Receiving Facility(or attach facility receipt) Date
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