HomeMy WebLinkAbout- Septic Pumping Slip - 59 JOHNNY CAKE STREET 12/12/2018 N -
Commonwealth of Massachusetts
City/Town of No. Andover
System Pumping record 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
filling out forms 1. System Location:
on the computer, -6 j
use only the tab _7_ 1 0 L4/11 4� 4 Cw
key to move your Address
cursor-do not No. Andover MA 01845
use the return - —..--..-.. ..._
key. City/Town State Zip Code
2. System Owner:
ad f C
Name
Address(if different from location)
--- ----- - ----.-._......._..... —
City/Town State � Zip Code
Telephone Plumber
B. Pumping Record
1. Date of Pumping --( 2. Quantity p Pum ed:
Date Gallons
3. Component: ❑ Cesspool(s) tf-Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LGI'IUQ If yes, was it cleaned? ❑ Yes ❑ No
5. Ob erved condition of component pumped:
..._ ----------__.
6. Systpm Pumped By:
r
Name' Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
A
l Bradford, MA
Hauler Date
1
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11112
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