HomeMy WebLinkAbout- Septic Pumping Slip - 59 WILLOW RIDGE ROAD 11/15/2018 Commonwealth of Massachusetts �
City/Town of No. Andover
= System Pumping Record
Form 4
9X-`N'r
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 j
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, �""'"1 ������ �� / d e„
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
teb 2. System Owner:
01'T
Name _...
reran
Ad ...-.___--- _....,.... _,
Address(if different from location)
__�_... _.... -__
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping l 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) [ Septic Tank El Tight Tank ❑ Grease Trap
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes M-9 If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pu p, d By.
Name Vehicle License Number
Stewart's_Septic_58 So Kimball St., Bradford,MA
Company
7. Location where were
contents ye disposed:
0 So. Mill St,., r$id ford. M...; ._..
— ...... _. --------- -------
.... /
Sig .�nat " �hauler .. Date
Signature of Receiving Facility(or attach facility receipt) Date
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