HomeMy WebLinkAbout- Septic Pumping Slip - 15 LONG PASTURE ROAD 12/12/2018 Commonwealth of Massachusetts
Y. Y
City/Town of No. Andover REV ,,�M D
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other form riay 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 j
the local Board of Health or other approving authority within 14 days from the pumping date in l
accordance with 310 rMR 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, City/Town State Zip Code
2. System Owner:
r l
Name __...._.
return
Address(if different from location)
.._..._. _ _. _...... ........ _.._
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping as _ 2. antity Pumped: -- -� --- __
Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): __.___....
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compone pumped:
8. Syste�j,,m d By: Tz--
.
f ..................
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents ewdis ed:
20 S . t1Qa.11 St_, Bradfo , M _..... _
..
.............-------------W------
' a e Date
Signature of Receiving Facility(or attach facility receipt) Date
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