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HomeMy WebLinkAbout- Septic Pumping Slip - 1070 OSGOOD STREET 2/4/2019 Commonwealth of Massachusetts w City/Town of No. Andover o 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 --�..._... .. —.— ...._..—_.__.._.—m....w_._.— 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: ' Name ........... Address(if different from location) '� �' �` � _. __........ �b" ... City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2, Quantity Pumped; Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease 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: Name Vehicie License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. IVIM St., Bradford, MA Signature of Hauler Date ......... ....__...... _................. Signature of Receiving Facility(or attach facility receipt) Date t5form4.doa 11/12 System Pumping Record•Page 1 of 1