HomeMy WebLinkAbout- Septic Pumping Slip - 288 FOSTER STREET 11/15/2018 Commonwealth of Massachusetts
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City/Town of No. Andover ��
System Pumping Record
Form 4
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DEP has provided this form for use b local Boards of Health. Other for its may be used,!'may
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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 No. Andover MA 01845
use the return —..
key. City/Town State Zip Code
2. System Owner:
Name _ .._..........._.....________........__
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. —.. _.. _..._ ..._....._........ . ....._....
Address(if different from location)
CityfTown State Zip Code
Telephone Number
B. Pumping Record
00
1. Date of Pumping D k b G-a
'" 2. Quantity Pumped: ll/n�s
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _...__
4. Effluent Tee Filter present? ❑ Yes XNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pump
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
Signature of Hauler Date
— -......... ...�. .........
Signature of Receiving Facility(or attach facility receipt) Date
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