HomeMy WebLinkAbout- Septic Pumping Slip - 507 JOHNSON STREET 11/15/2018 C Commonwealth of Massachusetts
City/Town of No. Andover
NOV I J
System Pumping Record
IMV�gq
Form 4 i
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:
use only the tab 59`7 -.---��,hnsc;n 'S/
on the computer, z
key to move your Address
cursor-do not No.Andover MA 01846
use the return
key. City/Town State Zip Code
ins
2. System Owner:
Name
mnen
....................-
Address(if different from location)
-----------
State Zip Code
Telephone Number
B. Pumping Record
L)C,)CI)
1. Date of Pumping Date uantity Pumped: Gallons
3, Component: ❑ Cesspool(s) Septic Tank El Tight Tank n Grease Trap
El Other(describe):
4. Effluent Tee Filter present? El Yes 0 If yes, was it cleaned? E] Yes ❑ No
5. Observed condition of componentpumped:
6. Sr a Pumped By.
Name Vehicle License Number
Stewa 's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:"""`
Q— . 1-1111,
-20- -Mll St. Bradford, MA,,,,
Signature of Haulp"."g- Date
Signature of Receiving Facility(or attach facility receipt) Date
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