HomeMy WebLinkAbout- Septic Pumping Slip - 66 BOXFORD STREET 1/22/2019 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 CMIR 15,361.
A. Facility Information
Important:When
filling out forms 1. System Location,
on the computer,
use only the tab �6
key to move your Address
cursor-do not No.Andover
use the return MA 01845
key. Cityrrown State Zip Code
2. System Owner:
Name gpj-L�
-Ad—dress(if different from location)
City/Town -State —'— Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: n Cesspool(s) EI-436ptic Tank El Tight Tank ❑ Grease Trap
n Other(describe):
4. Effluent Tee Filter present? El Yes El"N'o- If yes, was it cleaned? El Yes El No
5. Observed condition of component pumped:
� j
6. System Pumpe 'U4
Name Vehicle License Number
Stewaits Septic 58 So. Kimball St., Bradford MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradfe
Signature of HKU)ef
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doo-11112 System Pumping Record Page 1 of 1