HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 2/4/2019 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.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab (A —-----
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State 7,jp,, ode
2. System Owner:
P"
Name
reran
.................
Address if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
C
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. ComT onent: El Cesspool(s) F-1 Septic Tank D Tight Tank El Grease Trap
/
j v e, r , Ac
9Other(describe): - �"el I'll)
4. Effluent Tee Filter present? El Yes( ,...No If yes, was it cleaned? El Yes El No
5. Observed condition of component pumped:
0-fl. . .......
6. Sysferrf Pumped/p�: I
Name Vehicle License Number
_StqWapts.Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So, Mill St. Bradt ld, M
............
.................-
Signatu e of Hauler Date
—ignAture of Receiving Facility(or attach facility receipt) Date
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