HomeMy WebLinkAbout- Septic Pumping Slip - 230 FARNUM STREET 1/22/2019 ��C]������[��H����� n� K�������{���[!��*�� -
Commonwealth ^^/ Massachusetts
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Form 4 T{�/HOFHO�/M»mD0v
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 fonn, check with your
|Voa| Board of Health to determine the form they use, The System Pumping Record must be submitted to
the |ooe] Board of Health or other approving authority within 14 days from the pumping date in
accordance with 318CINR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
un the computer,
use only the tab
key m move your Address
cursor-do not
No. Andover MA 01845
use the return
key. cuy//n*n State Zip Code
2. System Owner:
Name
c*�/mwn S1aha Zip Code
Telephone�Number
B. Pumping Record
1. Date ofPumping Date2. Quantity Pumped:
Gallons
3. Component [l Cesspool(s) p, 8epticTank E7 Tight Tank Grease Trap
E] Other(describe):
4. Effluent Tee Filter present? [l Yen p1 No If yes, was it cleaned? [l Yee F� No
5. Observed
6. System Pumped B
mome - -' Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
U So,k8|U
/gnEtu�rAof au—le—r -- -Date I.............
Signature of Receiving Facility(or attach facility receipt) Date
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