HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 2/4/2019 (5) Commonwealth of Massachusetts
City/Town of No. Andover
__- System Pumping ecor
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, / w
use only the tab 1 L- W'�'
key to move your Address
cursor-do not No. Andover MA 01845
use the return _. —... _
key. City/Town State Zip Code
2. System Owner:
C, V
Name _ i __....
Address(if different from location)
p - -
City/Town State Zi Code
_ Telephone Number .
B. Pumping cord
1. Date of Pumping Date 16— 2. Quantity Pumped:
Gallons
3. Com onent: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe): -
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
/'n_'44A_1z
6._5y em Pum yd:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St, Bradford MA
Company
7. location where contents were disposed:
o So. Mille Bradford MA
I
/- —
ignature of He pate
Signature of Receiving Facility(or at#ach facility receipt) pate
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