HomeMy WebLinkAbout- Septic Pumping Slip - 174 INGALLS STREET 12/12/2018 Commonwealth of Massachusetts w City/Town of No. Andover - _ & SystemPumping Record ' . Farm 4 l i p rl; hta i[� l I Li4'I� 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 1 Important:When filling out forms 1. System Location: on the computer, the tab _jj_ key to use onmove your Address �� /� cursor-do not No.Andover MA 01845 use the return -------- _____..__. ----- key. Cityrrown State Zip Code 2. System Owner: Name - rBnan .............-- Address(if different from location) City/Town — State Zip Code Telephone Number _ B. Pumping Record 1. Date of Pumping ©ate 2. Quantity Pumped: - Gallons 3. Component: ❑ Cesspool(s) 2 Septic Tank [l Tight Tank ❑ Grease Trap ❑ Other(describe): ---_____._ 4. Effluent Tee Filter present? ❑ Yes No ifWyes, s it cleaned? Yes No❑ 5. Observed condition of component pumped: 6. Sys Pumped By' Name' Vehicle License Number Stewart s Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. Mi ., Bra rd, Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc-11/12 System Pumping Record-Page 1 of 1