HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 11/15/2018 (11) Commonwealth of Massachusetts
City/Town of No. Andover
System Pumping Record
Form 4
U,
DEP has provided this form for use by local Boards of Health. Other forms 1-ha" b6'6ied,'b'ut the
y
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
use the return 01845
key. City/Town State Zip Code
2. System Owner:
—A
Name
Address(if different from location)
City/To ivn -St—ate -- Z' Code
Telephone Number
B. Pumping Record
6 1. Date of Pumping
Date 2. Quantity Pumped:'
5*(Tz)Gallons
3. Component: M Cesspool(s) ❑ Septic Tank F1 Tight Tank ❑ Grease Trap
6VOther(describe): te
4. Effluent Tee Filter present?� ❑ Y 0 If yes, was it cleaned? El Yes El No
5. Observed condition of co ponen pumped:
6. S Pumped By:
Name Vehicle License Number
.Stewart's Septic 58 So. Kimball St., BradfordMA
Company
qVie—If
7. Location where contents were disposed:
20 So. Mill radford, MA
Si nature,of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Da#e
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