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Home My WebLink About- Septic Pumping Slip - 225 BRIDGES 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 Location: on the computer, 1) -) - use only the tab br ' - d &- -5 ----- "�Cl key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town ................... .......... key. State Zip Code 2. System Owner: reb Name re ssn ............... ................... ............................................ Address(if different from location) CityrFown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallo 3. Component: ❑ Cesspool(s) ["°"Septic Tank F-1 Tight Tank F Grease Trap © Other(describe): 4. Effluent Tee Filter present? El Yes E] No If yes, was it cleaned? E] Yes F] No 5. Observed condition of compone dumped: 6. I urnped By:-V7 ----------- "—Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were- posed: 2 Bradfqr .............. 72 —----- ------- 'Sig ure of H r Date . ...........- .......... Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc-11/12 System Pumping Record-Page 1 of 1