HomeMy WebLinkAbout- Septic Pumping Slip - 135 JOHNNY CAKE STREET 1/22/2019 Commonwealth of Massachusetts
W City/Town of No. Andover
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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 _......._t -._
key to move your Address _..
cursor-do not No. Andover MA 01845
use the return — ........__..__— . .....__._w
key. City/Town State Zip Code
2, System Owner:
tab
Name _.... _.__
reaun
Address(if different from location)
City/Town State Zip Code
_...............__
Telephone Number
B. Pumping Record
1. Date of Pumping / 2, Quantity Pumped:
Dale Gallons
3. Component: ❑ Cesspool(s) Qeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): .....
4. Effluent Tee Filter present? ❑ Yes [,�.N`b If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumpe�y:
Name Vehicle License Number
Stewart's Septic 58 So, Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
.20 So. Mill St., Br d, MA
- .......__ Vule ---
Siggnature of Date
_ ...... _...... —_,_....w�..--.. ..............__ _,,........._.
Signature.of...._.Receiving�__..Facility(or attach facility receipt) Date
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