HomeMy WebLinkAbout- Septic Pumping Slip - 59 PADDOCK LANE 12/12/2018 Commonwealth of Massachusetts
City/Town of No. 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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Locatio
on the computer,
use only the tab
key to move your Address'
cursor-do not No. Andover MA
use the return -—----------- 01845
key. City/Town State Zip Code
2. System Owner:
Name ... ........
remvn
Address(if different from location)
-bt-y--/Town7--1 State Zip Code
Telephone Number
8. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: [3 Cesspool(s) ZSeptic Tank El Tight Tank El Grease Trap
D Other(describe): --------
4. Effluent Tee Filter present? R Yes No if yes, as it cleaned? ❑ Yes Na
IT7
5. Observed condition of component pumped: / 0
e/5
6. :Sym7m Pumped y:
ame Vehicle License Number
Stewart's Septic 58 So. Kimball St., q.radford,MA
Company
7. Location where contents were disposed:
20 So. Mi t., Br for
....... -------
S gnature of Haule Date
Signature �R�-ece—ivi-n-g—Fa'c'-ility—(or--at-'t"�a�-'c-'h facility receipt) Date ----------—
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