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HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 1/22/2019 (5) Commonwealth of Massachusetts = v City/Town of No. Andover qm System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other farms may be used, but the inform ation must be substantially the same as that provided here. Before using this farm, 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. I A. Facility Information Important:When filling out forms 1. System Location: on the computer,use only the tab ._ _.. ..........� �.�......_.�.._._....._. _.... ,.....___ �.! ._ .w. ._......._..--.w_.__.......__ _._.... __....._....._....._ key to move your Address cursor-do not No. Andover MA 01845 usethe return _..__._. ....___ ...._........ — _._...... ......_....._..—____...._. �... ......___ ........_.._.... key. Cityrrown Skate Zip Code 2. System Owner: Name �eltnn ... — - _.... _.—..m. _....._.. — Address(if different from location) City/Town State Zip Cade Telephone Number B. Pumping Record Date � Gallons 1. Date of Pumping 2. Quantity Pumped: 3. Component: © Cesspool(s) ❑ Septic Tank ❑ Tight Tank Q Tease Trap ❑ Other(describe): _ 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? © Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: a Vehicle License Number Stewart's Septic 58 So Kimball St., Bradford,MA Company 7. Location where contents were disposed: i 20 So, MITI St., Bradford, MA Signature of Hauler Date —_._. .—._.. ....t......... —.... _.. _.. ..... Signature of Receiving Facility(ar ata chw facility rec cee-ipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1