HomeMy WebLinkAbout- Septic Pumping Slip - 7 CARLTON LANE 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 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 ❑ el Nf elf 411
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
renan
Address(if different from location)
-61"t"y/T'own, State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date G2(llons
3. Component: El Cesspool(s) ❑ Septic Tank R Tight Tank Ej Grease Trap
F-1 Other(describe): ..............................
4. Effluent Tee Filter present? F-1 Yes Ej,,N6 If yes, was it cleaned? n Yes ❑ No
5. Observed condition of component pumped:
....................
6. Sys7 Pumped j3y:
Na a Vehicle License Number
Stewart"--eptic 58 So. Kimball St., Bradford MA
Company
(7/"Location
Coca t i o n w h re contents were disposed:
-2-0-S Mill Bradford, MA
Si a re of Ha Date
Signature of Receiving Facility(or attach facility receipt) Date
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