HomeMy WebLinkAbout- Septic Pumping Slip - 265 HAY MEADOW ROAD 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 j
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351,
i
A. Facility Information -
Important:When
filling out forms 1. System Location:
on the computer, � ,,�-- �°
use only the tab _....._.. .` ....._ yf i"'_'t �144-_ )�f �: __............._. — —
key to move your Address
cursor-do not No. Andover MA 01845
use the return — — _......-..___
key. Cityrrown State Zip Code
ren 2. System Owner-
Name
rerwn
Address(if different from location)
CitylTown State Zip Code
Telephone Number
....... ._
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gailons
3. Component: ❑ Cess ool(s) N,,Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe): _- .......
4. Effluent Tee Filter present? ❑ Yes M No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System P edy:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
1
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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