HomeMy WebLinkAbout- Septic Pumping Slip - 466 WINTER STREET 10/11/2018 11 2018 09:59 AS Dev/Stewarts 9783736611 page I
_<C�x Commonwealth of Massachusetts RECEIVED
City/Town of No. Andover
System Pumping Record 'T'oWt4(X��NORI H ANDOAM
Form 4 iIEAUM U�!A`AMWENT'
DEP has provided this form for use by local Boards of Heaith. 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 CIVIR 15.361.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not No.Andover MA 01845
use the return
key. CiWTown State Zip Code
2. System Owner:
6M
Address(if different from IOCWIDn)
City/rown state -iip"Code .........................
Telephone Number
B. Pumping
1. Date of Pumping 2. Quantity Pumped: __La a agate Gallons
3. Component: El Cesspool(s) [Septic Tank 1771 Tight Tank El Grease Trap
171 Other(describe):
4. Effluent Tee Filter present? [I Yes M/No If yes, was it cleaned? [:1 Yes 171 No
5. Observed condition of component pumped:
---------- -
6. Sys m Pumped§y:
�Vehicle-License Number-Stewart's Septic 58 So. Kimball St., Bradforq,".
Company
7. Location where contents were disposed:
U-:me
20 So. Mill St. Bradford-, MA
"v"
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----Signature ------
of au er Date
r,of
Signature of Race n acil' (or attach facility receipt) Dale
�ei g�
t5form4,doG-11112 System Pumping Record,Page 1 of 1