HomeMy WebLinkAbout- Septic Pumping Slip - 57 CHRISTIAN WAY 10/17/2018 Commonwealth of Massachusetts
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M _ = 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 Lorratinn:
on the computer, r
use only the tab _...... _... .
key to move your Address
cursor-do not No. Andover MA ( 01845
use the return _ _ ._.........
key. City/Town State Zip Code
!� 2. System Owner:
�t
Name
rerun
Address(if different from location)
_...._._�---- ---.................__.... ... _........__._ ----.....
City/Town State Zip Code
Telephone Number
B. Pumping Record
/S
1. Date of Pumping pat 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _.._.... ......_ ......___.._
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. .Sys yPumped
_
AL
� .___...._....__. _..
Name ( Vehicle License Number
Stewart' etc 58 So. Kimball St., Bradford,MA
Company
7. 41�atureof
e contents were disposed:
20 , Bradford, MA
. ........ AD
Si
ler Date
Signature of Receiving Facility(or attach facility receipt) Date
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