HomeMy WebLinkAbout- Septic Pumping Slip - 115 LACONIA CIRCLE 11/15/2018 Commonwealth of Massachusetts
^_ r
City/Town of No. Andover
System Pumping Record
Farm 4s
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 computerlei
,
use only the tab _ 115 _... c - .... ..0 ,... ............................... _......
key to move your Address
cursor-do not No. Andover MA 01845
use the return _._ _ _......_.........._.
key. City/Town State Zip Code
2. System Owner:
r�
Name
rerwn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. bumping Record
1. Date of Pumping 2. Quantity Pumped: `
Date Gallons
3. Component: ❑ Cesspool(s) ASeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --------------------------------- -_---
4. Effluent Tee Filter present? ❑ 'Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
C. System P , ed 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 Hauler Date
------------- _.......,,.
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1