HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 11/15/2018 (5) Commonwealth of Massachusetts
City/Town of No. Andover
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System Pumping Record h T/ 9 0
Form 4 iiov,!",�Oil"Hi,)-i P0
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 CIVIR 15.361.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, '35-1 i
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:
Al 3-69 V
Name
mnm
Address(if different from locatlon--) -
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping icl- 2. Quantity Pumped:
Date —dailons,
3. Component: M Cesspool(s) 0 Septic Tank n Tight Tank rease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes n--N�o If yes, was it cleaned? El Yes ❑ No
5. Observed condition of comp nt pump
6. 7yste Pumped By"" e
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
ill St., Bradf rd-,-War,
ZSignature war" Date
-Signature of Receiving—Facility(or attach facility receipt) Date
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