HomeMy WebLinkAbout- Septic Pumping Slip - 125 ROCKY BROOK ROAD 11/15/2018 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 &e 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 they computer, ° a
use only thehe tab I �' � �•�-
key to move your Address
cursor-do not No. Andover MA 01845
use the return !Town Clt
key. y State Zip Code
t�
2. System Owner:
Name
Address(if different from location)
Clty/Town State i C de
Telephone Number
B. Pumping kecord
Sa�— SefpTank
�l1. Date of Pumping Date QuantityPumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — —
4. Effluent Tee Filter present? ❑ Yes l o If yes„ was it cleaned? ❑ Yes ❑ No
5. Observed condition of component mp-d: <
��7 I I _)
6. Sys hump B :
Name Vehicle License Number
Stewart l St., Bradford,MA
Company
1
7. Location where contents were disposed:
20 . Mill St., BradjDrcL,MA
f ! 5'
Si nature of Hauler <.a. Date
Signature of Receiving Facility(or attach facility receipt) Date
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