HomeMy WebLinkAbout- Septic Pumping Slip - 531 FOREST STREET 1/22/2019 'L I
Commonwealth of Massachusetts
R
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 CIVIR 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
use the return MA 01845
key. Cltyfrown State Zip Code
2. System Owner:
Name
Address(if different from location)
Cftyfrown State Zip Code-
B. Pumping Re cord Telephone Number
1. Date of Pumping Date Z 2. Quantity Pumped:
Gallons
3. Component: F1 Cesspool(s) dSeptic Tank M Tight Tank n Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? [:] Yes []'-No If yes, was it cleaned? [:1 Yes Ej--No
5. Observed condition of com onent pumped:
6. System Pumped By
Name' Vehicle License Number
Stewart's Septic 68 So. Kimball St,, Bradford,MA
Company-
7. Location where contents were disposed:
20 So. Mill St,,Bradford, MA
II
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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