HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 2/4/2019 (9) IL I
Commonwealth of Massachusetts
u City/Town of No. Andover
System u m i ng Recor
Form 4
i
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`'! pumping date in
accordance with 310 CMR 15.351. '
I
A. Facility Information
Important:When 0
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 _.--._..__-........._ —
key. City/Town State _.—._ Zip Code
dab 2. System Owner:
Al- "
Name
Address(if different from location)
City/Tawn 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 Urea e Trap
❑ Other(describe): -° � `
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
..0"
6. System Pumped By:
' ~
Namem mm -- 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 Hauler Date
-— __....
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record-Page 1 of 1