HomeMy WebLinkAbout- Septic Pumping Slip - 250 ABBOTT STREET 11/26/2018 Commonwealth of Massachusetts .
City/Town of o. Andover � C��� t
System Pumping Record
Form 4
L1 i.i i�i ENI'
DEP has provided this form for use by local Boards of Health. Other forms mar a 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 � �
key to move your Address
cursor-do not No.Andover MA 01845
use the return
key. Cityfrown State Zip Code .
2. System Owner:
�1 0
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ._f 2 Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic 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;®�`�.
T7-d
6. System Pumped By:
Vehicle License Number
Stewart's Septic 58 So. Kimbat t., 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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