HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 4/22/2019 (5) Commonwealth of Massachusetts
w 4 p City/Town of No. Andover
System Pumping eo r
#7 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 15,351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, t Gyp use only the tab
key to move your Address
cursor-do not No.Andover
use the return MA __ 01845
ITown
key. Ci ty State Zip Code
2. System Owner:
rib
Name —
renen
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: ' ---
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
N
5, Observed condition(�f component pumped:
6. System Pump -da By:
_. . ..
e Vehicle License Number
Stewart's Septic 58 So. Kimb St., Bradford,MA
Company
7, Location where contents were disposed:
0 So, Mill St, adford, MA 1
S au
,,,.., '
I„fir ' •, --
nature of H ' � Date _
Signature of Receiving Facility(or attach facility receipt) Date
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