HomeMy WebLinkAbout- Septic Pumping Slip - 492 SHARPNERS POND ROAD 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 14
key to move your Address
cursor-do not No, Andover MA 01845
use the return -
key. di—ty/Town State Zip Code
2. System Owner:
jab
Name
Address(if different from location)
...........
Cityl-Fown State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping Date 2. Quantity Pumped: Gallons/ —---------
3. Component: ❑ Cesspool(s) Septic Tank F1 Tight Tank Ej Grease Trap
El Other(describe): ....... .......
4. Effluent Tee Filter present? E] Yes R No If yes, was it cleaned? El Yes 0 No
5. Observed condition of component pumped:
V X
6. System Pumper.
l.,B�
Name Vehicle License Number
Stewart's Septkc 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
..............
Signature of Hauler Date
7—r "— " - ' —a' — t i—ty' - — '.........
Signature oi Receiving Facility(or facility receipt) Date
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