HomeMy WebLinkAbout- Septic Pumping Slip - 295 FOREST STREET 11/15/2018 Commonwealth of Massachusetts
City/Town of No. Andover
System Pumping Record
Form 4 (,v
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 No. Andover MA 01845
use the return ..............
key. City/Town State Zip Code
2. System Owner, rt
Name
repro
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 7 2. Quantity Pumped: Gallons
3. Component: El Cesspool(s) ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
4'66 A
6. Syst Pumped
Vil ?V'w"
Name Vehicle License Number
Stewart's Ciptic 58 So. Kimball St., Bradford,MA
Company
7r. ocation jwhe contents were disposed:
So Mil B
20 So. Mill S Bradford, MA
Hauler
sNig re o Hauler
Signature of-Receiving Facility(or attach facility receipt) Date
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