HomeMy WebLinkAbout- Septic Pumping Slip - 380 SUMMER STREET 10/17/2018 Commonwealth of Massachusetts
City/Town of No. Andover
System Pumping Record
Form 4 J' J
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 CIVIR 15,351.
...............
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 3 tb
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:
Ca
Name
reman
----—------
Address(if different from location)
.......................... ...............
City/Town State Zip Code
............
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gall s
3. Component: El Cesspool(s) ptic
ptic Tank ❑ Tight Tank ❑ Grease Trap
US'4
F-1 Other(describe): .........................111................
4. Effluent Tee Filter present? [] Yes [�/No If yes, was it cleaned? F-1 Yes El No
5. Observed condition of component pumped:
6. Syst Pumped By
Ngme Vehicle License Number
Stewart'6e'ptic,58 So. Kimball St., Bradford MA
Company
T,,--Location wk6 e contents were disposed:
20�$o. Mill S radford, MA
...............................
........................
tqtna of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11/12 System Pumping Record-Page 1 of 1