HomeMy WebLinkAbout- Septic Pumping Slip - 65 SPRING HILL ROAD 3/12/2019 Commonwealth of Massachusetts i
u W City/Town of No. Andover
System Pumping ec 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
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 f
accordance with 310 C M R 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 -——
cursor-do not l�lo Andover use the return MA 01845
key. Citylrown State
Zip Cade
2, System Owner:
tsb
-ivame e-
-
reorn _�
Address(if different from locatlon) �-
State Zip Code
Telephone Number
B. PumpingRecord -
c,
1. Date of Pumping ---1-f— 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Evseptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes P""'No If es„ was it cleaned?Y ❑ Yes ZL,No
5. Observed condition of co ponent p mped:
6. System Pumped
( ,
Name Vehicle License Number -
Stewart's Septic 58 So. Kimball St., Bradford MA t
Company
7. Location where contents were disposed: {
20 So. Mill St,, Bradford, MA
Signature of Mauler Date
Signature of Receiving Facility(or attach facility receipt) Date -
teform4.doc•11/12
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