HomeMy WebLinkAbout- Septic Pumping Slip - 29 BRADFORD STREET 12/12/2018 Commonwealth of Massachusetts
City/Town of Flo. 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 CUIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ar-d-
key to move your Address
cursor-do not No. Andover MA 01845
use the return --
key. City/Town State Zip Code
VQ 2. System Owner:
----C--L< -/................................
Name
Address(if different from location)
-----------.......... ---------
City[Town State Zip Code
-------------
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
D9te Gallons
3. Component: M Cesspool(s) t3/Septic Tank E] Tight Tank n Grease Trap
El Other(describe): ............
4, Effluent Tee Filter present? F] Yes No If yes, was it cleaned? 0 YesNo
5. Observed condition of com -Int pumped:
6. Svstem umpe 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
-—— —------------------
'Sign iure of kiec"e--iving—Facility(or attach facility receipt) Date
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