HomeMy WebLinkAbout- Septic Pumping Slip - 1785 SALEM STREET 10/17/2018 Commonwealth of Massachusetts
City/Town of No. Andover
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
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 Loc ion:
on the computer,
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
............
Name
--- -------
Address(if different from location)
-6-ity/Town State ZipCode
Telephone Number
B. Pumping Record
1. Date of Pumping
Date 4. Quantity Pumped: Gallons
3. Component: F-1 Cesspool(s) Septic Tank F-1 Tight Tank F-1 Grease Trap
❑ Other(describe): ..........
4. Effluent Tee Filter present? El Yes [2 Z.
No If yes, sit cleaned? r_1 Yes M No
5. Observed condition of component Pumped:
6. Sy ml Pumped
Name— _ ,2) Vehicle License Number
Ste Name
Septic 58 So. Kimball St., Bradford,MA
........................
Company
7. Location where contents were disposed:
20 So. Mill St, adford, MA ..... .... .
- i/rgna—tureof��Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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