HomeMy WebLinkAbout- Septic Pumping Slip - 226 ABBOTT STREET 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 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:
iT-e
Name
Address(if different from location)
City/Town State Zip Code
B. Pumping Record Telephone Number
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: R Cesspool(s) Septic Tank n Tight Tank r-1 Grease Trap
El Other(describe):
4. Effluent Tee Filter present? M Yes [Z/No If yes, was it cleaned? El Yes No
5. Observed condition of component pumped: -4
................
6. Sy Pumped BV
r
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St Bradford,MA
-Company
7. Location where contents were disposed:
S W20 So. Mi Br rd
L -----------
gnature of Haule Date
Signature of Receiving Facility(or attach facility receipt) Date
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