HomeMy WebLinkAbout- Septic Pumping Slip - 246 RALEIGH TAVERN 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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Lo tion:
on the computer, q�g
use only the tab
key to move your AdPrL
cursor-do not No. Andover MA 01845
use the return . ......---- ----
key. City/Town State Zip Code
2. System Owner:
c"
Name
renrn
Address(if different from location)
City/Town State Zip Code
.................................
Telephone Number
B. Pumping Record
/r -7) 0
"
1. Date of Pumping D , a
ate 2. Quantity Pumped: e ..................
3. Component: El Cesspool(s) 9-4ep`2ic Tank El Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? F-1 Yes If yes, was it cleaned? ❑ Yes 0 No
5. Observed condition of component pumped-
............ .............
6. Syste umped By,
.............
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill,St., Bradford, MA-,
.... .............................
--Signature of Raul r Date
Signature of Receiving Facility(or attach facility receipt) Date
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