HomeMy WebLinkAbout- Septic Pumping Slip - 53 MARIAN DRIVE 1/22/2019 Commonwealth of Massachusetts
City/Town of No. Andover
r
Systemu i r Form 4
DBP has provided this form for use by local Boards of Health. Other forms may be used, but the t
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 t
Important.:When
filling out forms 1. System Location:
the computer,
he tab,
use
, ,,) 1
�
key to move your Address [
cursor-do not No.Andover
use the return City/Town ITown MA 01845
key. State Zip Code .
2. System Owner:
Name
moan
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping oats 2. Quantity Pumped: Ga€Ions ,
3. Component: ❑ Cesspool(s) [L-1--geptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): —__._...
4. Effluent Tee Filter present? ❑ Yes o if yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped
c�
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
Signature off-fauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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