HomeMy WebLinkAbout- Septic Pumping Slip - 350 HOLT ROAD 3/12/2019 Commonwealth of Massachusetts
u City/Town of No. Andover
System um i so r
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 1
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,
i
I
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, r
use only the tab µ .m 1 0I `TA'
key to move your Address
cursor-do not No. Andover MA 01$45
use the return - --..-. — _._.
key, City/Town State Zip Code
Q 2. System Owner: 1
1
Name
nnun
------------
----------
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
? 1
6. System Pumped By:
t r�
Name Vehicle License Number
Stewart's Septic 5$ 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