HomeMy WebLinkAbout- Septic Pumping Slip - 66 BOXFORD STREET 2/4/2019 Commonwealth of Massachusetts
City/Town of o. 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 16.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, L30 ®
use only the tab
key to move your Address --
cursor-do not No.Andover
use the return Ci MA 01845
/Town
key. tY State Zip Code .
2. System Owner:
Name
yam
Address(if different from location)
City/Town State
Zip Cade
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:Date y p Gallons
3. Component: ❑ Cesspool(s) 0-860tic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes El 1qo If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumpe y t
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St. Bradford MA
Company
7. Location where contents were disposed:
20 So. Mill St. Bra rd
Signature of H ale Date
d
Signature of Receiving Facility(or attach facility receipt) Date
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