HomeMy WebLinkAbout- Septic Pumping Slip - 784 WINTER STREET 11/15/2018 It I
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, 'I if 'A ter
use only the tab
key to move your Address
cursor-do not No. Andover MA 01846
use the return
key. City/Town State Zip Code
2. System Owner:
Name
rsrwn
-Address:(if different from location)—------
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping oi-
-A�L 2. Quantity Pumped:
Date Gallons
3. Component: ❑F-1 Cesspool(s) Septic Tank Fj Tight Tank ❑ Grease Trap
El Other(describe): ......
4. Effluent Tee Filter present? EJ Yes No If yes, was it cleaned? n Yes F-1 No
5. Observed condition of component pumped:
sands ----—-----
6, System P ed By:m
m VehlcleThZ—e4ns-X.iumber
Stew Septic 58 So. Kimball St,, BradfordMA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
Signature-ofiHauler -6a—te -
Signature of Receiving Facility(or attach facility receipt) Date
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