HomeMy WebLinkAbout- Septic Pumping Slip - 50 TIFFANY LANE 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 Location:
on the computer,
use only the tab
key to move your Address ...........
cursor-do not State
No. Andover MA 01845
use the return City/Town -------
key. Zip Code
2. Syste Owner',
-15e
Name
rndrn
Address(if different from location)
City/Town State -Zip Code---------
Telephone Number
B. Pumping Record
1. Date of Pumping 'bate Quantity Pumped. Gallons
3. Component: El Cesspool(s) Tank ❑ Tight Tank El Grease Trap
Yptic Taut
El Other(describe):
Y a 0
4. Effluent Tee Filter present?
- ll if yes, was it cleaned? ❑ Yes El No
F-1
5. Observed condition of component pu ped:
1--51
6. S Pumped By:
y
Nam6-1 Vehicle License Number
Stewartl s Septic 58 So. Kimball St. §radford,MA
Company
7. Location where pontents were disposed:
0 So. Mill St. raLddford, MA
Sig ature of Ha r Da Ae
Receiving
-(or-atta receipt) Date
Signature of Receiving Facility' ch facility
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