HomeMy WebLinkAbout- Septic Pumping Slip - 1030 JOHNSON STREET 4/22/2019 �. Commonwealth of Massachusetts
= y City/Town of No. Andover
:. System Pumping Record
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,
use only the tab ff7tY_1__....
_
key to move your Address
cursor-do not No. Andover MA 01845
use the return _.....-.___._._..__._. ._. __ ........---.-.
key, City/Town State Zip Code
2. System Owner:
re6 I �
e
Name
reavn
Address(if different from location)
City/Town State Zip Code
............-.......... ------............
_.
Telephone Number
. Pumping Record
Eat D-
. �r �
1. Date of Pumping -- 2. Quantity Pumped: _......._.....
GalEar7s
3. Component: ❑ Cesspool(s) a6ptic Tank ❑ Tight Tank ❑ Grease Trap
El Other(describe); _ww.__-
4. Effluent Tee Filter present? ❑ Yes "No If yes, was it cleaned? ❑ Yes' -No
5. Observed condition of component p mped:
6. System Pumped By:
---
Narr Vehicle License Number
Stewart'se ti 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
SEgnatur of h 06ler Date
Signature of Receiving Facility(or attach facility receipt) ...-_... Data_
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