HomeMy WebLinkAbout- Septic Pumping Slip - 21 CLARK 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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return ......................
City/Town State 1P Code
key.
2. System Owner:
VQ
jr
Name
/BMR ....... .........
Address(if different from location)
.............---------------
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping T.......... 2. Quantity Pumped: ..................Date Gallons
3. Component: ❑ Cesspool(s) E] Septic Tank n Tight Tank F-1 Grease Trap
(,Other(describe):
4. Effluent Tee Filter present? F-1 Yes No If yes, was it cleaned? E] Yes R No
5. Observed condition of conriponent pumped:
------------
6. Sy tem Pumped By: pl
ame Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
........................--------------
Company
7, Location where contents were disposed:
20 So. Mill St., Bradford, MA ..........
Signature of Hfiulgr Date
--—---------
Signature of Receiving Facility(or attach facility receipt) Date
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