HomeMy WebLinkAbout- Septic Pumping Slip - 115 LACONIA CIRCLE 11/26/2018 �
Commonw
ealth of Massachusetts
City/Town of No. Andover
?
System Pumping Record N�T R
ovt4 CA:
Form 4 l
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,
use only the tab - / /�- I tt 6,611vLe' l
key to move your Address
cursor-do not No.Andover MA
use the return 01845
key. City/Town State Zip Code
2. . System Owner: /I
fed
Name
rim
Address(if different from location)
CityCrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping zo— 2. Quantity Pumped:
[lateGallons
3. Component: El Cesspool(s) )<Septic Tank F-1 Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? F-1 Yes El No If yes, was it cleaned? M Yes n No
5. Observed condition of component pumped:
6,
6, System Pumped By:
Name Vehicle License Number
Stewarfs 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
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