HomeMy WebLinkAbout- Septic Pumping Slip - 283 CAMPBELL ROAD 12/12/2018 Commonwealth of Massachusetts
Q w City/Town/Town of No. Andover
_ System umpinRecord
Form 4
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 16.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
an 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:
Name
renrn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping kecord
1, Date of Pumping date — 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) peptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — --
4, Effluent Tee Filter present? ❑ Yes [n,"No If yes, was it cleaned? ❑ Yes 'E]--"Jo
5. Observed condition of componen pumped:
6. SStm y Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradfard,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
Signature of Hauler pate
Signature of Receiving Facility(or attach facility receipt) Date
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