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HomeMy WebLinkAbout- Septic Pumping Slip - 39 HAY MEADOW ROAD 4/22/2019 Commonwealth of Massachusetts W City/Town of No. Andover, MA Y System Pumping Record u Form 4 DEP has provided this form for use by local Boards of Health. Other farms may be used, but the information must be qubstantially 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: key to use �oveyo tab urr Address C.,; 1, „' cursor-do not MA use the return key. City/Town State Zip Code 2. System Owner: r� - . Name ....._. _------ ....__.... _._. �cnan 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) Septic Tank ❑ Tight Tank © Grease Trap ❑ Other(describe): __.-------__ ---_-_____- 4. Effluent Tee Filter present? ❑ Yes u NO If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: .tom"=�'��..l�". _.._.._. .. ........_........... ..._._..�._...—._. 6. System Pumped By: ame 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 ignat re Hauler .. Date .-..__..L.-.. _..__.....1 ...... _. Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11112 System Pumping Record•Page 1 of 1