HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 2/4/2019 (7) Commonwealth of Massachusetts
F City/Town of No. Andover
F. ,stem Pumping Record
vu•9'� 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 _ '
key to move your Address w^ _
cursor-do not
use the return No. Andover
�.__.._ _._,_.. _ .w�.. .._.._ ..__.._...key. City/Tawn MA �__ __ 01845
State _.-..—._..._.._.._.. —
,� 2. System Owner: �� . Zip
code
f ct.l e. Al j
ret�n
Address(if different from locatipn}
City/Tovvn _.—__.._._..w_..—.._—.._
State .._...�...w_.._..__..—.._._.._....
Zip Code
. Pumping ecord ____.
Telephone Number
1. Date of Pumping
2. Quantity Pumped: GaPp rVs
�-
.w_..__
3. Component: ❑ Cesspool(s) ❑ Tank Septic p ❑ 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. System Pumpe By:
n
Name ......
Stewart s Se tic 58 So. Kimball St., Bradford Mq vehicle I-icense Number
Company __.____m .w__ ___..w=
7. Location where contents were disposed:
20 So, Mill St., Br __-
MA
Signature a auler —
Date
Signature of Receiving Facility or attach facility receipt} pate
t5form4.doc- 11/12
System Pumping Record•Page 1 of 1