HomeMy WebLinkAbout- Septic Pumping Slip - 432 SALEM 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 CMR 15.351.
i
A. Facility Information
Important:When
filling out forms 1. System Location
on the computer,
use only he tab ) //
key to move your Address
cursor-do not No. Andover MA 01845
use the return —._....._. _.. _...�........ �.. ......_.... _......
key. City/Town State Zip Code
2. SystemTT
ner:
rs6
Name _ ....__......
retwn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Plumping Record
,� rat.'_...._— albs
1. Date of Pumping2. Quantity Pumped:21JI
y p
3. Component: ❑ Cesspool(s) aOeptic 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. Sys e Pumpe y:
Name Vehicle Lic e umber
Stewa s e tic 58 So. Kimball St., Bradford,MA
...
Compan
7f Location whet contents were disposed:
20 Sa. Mill St. Bradford, MA
Signs re o Hauler Date
............... _. ...._ ._.._-.w—..... _.__.
Signature of Receiving Facility(or attach facility receipt) Date
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