HomeMy WebLinkAbout- Septic Pumping Slip - 30 OXBOW CIRCLE 10/17/2018 Commonwealth of Massachusetts
City/Town of No. Andover
W° System Pumping Records
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. f
A. Facility Information
Important:When
use only the tab anon:
on the computer, 1. System Location:
filling Y 1/
key to move your Address
cursor-do not No, Andover MA 01845
use the return _._..._.._ _ _. _w.._.....
key. City/Town State Zip Code
2. System Owner:
r� t
Name _..._ _.. .....__._
reran
_...._ _.. _ ..... .......... ._._._
Address(if different from location)
Cityf4"own State I
N
f� Co e
Telephone Number
B. Pumping Record
1. Date of Pumping ..aat - --� -`" 2. Quantity Pumped: Gallo
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _..
4. Effluent Tee Filter present? ❑ Y s- - No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component p mped:
6. Sys etxump By: 16 t
J I • w `
NaS vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford MA
Company
7. Location where contents were disposed:
2G o. Mill St., Bradford, MA
a#ure of Haue _.._ ....._...� ..........._ Date
_ ---------------------
�....—.
Signature _.. .........._ __..._ __.
1
S.
of Receiving Facility(or attach facility receipt) Date
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