HomeMy WebLinkAbout- Septic Pumping Slip - 350 SHARPNERS POND ROAD 12/12/2018 Commonwealth of Massachusetts ''
City/Town of No. Andover
System Pumping Record
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r` 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 CMR 15.351.
A. Facility Information
Important:When
use only the tab On:
out forms 1.
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on tge computer, ys� OC
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town _.....__ ._.......... State Zip Code
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rsb 2. System Owner:
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Name _._......_.._.._. ......... .. ..__..__.. __...
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Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping-Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
El Other(describe):
4. Effluent Tee Filter present? ❑ Yes [� No If yes, was it cleaned? ❑ Yes /No
5. Observed condition of component pumped; --)
_.... t. 4,,.•..
6. System Pumped By '
ame Vehicle License Number
Stewart's Septic 58 So Kimball St., Bradford,MA
_
Company
7. Location where contents were disposed:
MA
Signature of HAuler Date
.__.......... .... �.... ......
Signature of Receiving Facility(or attach facility receipt) Date
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