HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 5/8/2019 (5) CrOi"'
fy ,rir fJ%laJ���'���
Commonwealth of Massachusetts
J o91 �^ fi fs l
,r u i/Grp
City/Town
r"lour f/%0/fu
'I
N"
System Pumping Record
4AF n
h
'sr,
Form 4
DEP has
�� Mw 4 MY'Y �`4b O4irw" v
6i«,III VIU°"
. j
provided this form for use by local Boards of Health. Other forms may used, but the
information must substanti alll the same as,that provided here. Before using this tort, check with your
local, Board "t Heafth t determine the form they use. The System Vamping Record r rust be submitted t
the local Board of Health or other approving authority within 14 days from the pumping date its
accordance with 3 1 C M R 15.35 1. `
A. Facility Information
Important:When
filling out farms 1. System Location:
on the computer,
use only the tadVU
key to move your Address
cursor-do not
0 1845
use the return '
Andover. ".. � A,
I .
Cilyffown State Zip Code
2 System,Owner:
i
Narn
i
Addressi different from Io tion
i
City/Town City/Town State Zip,Code
Telephone Number
B. Pumping Record
. Date Pumping � 2.
.. .�"m .� .�m�.��.��..�� Quantity is
Cate Gallons
3. Component: Cesspool(s) [:1 Septic Teak Fight Tank Grease Trap
s luc4e
[D,o*06ffier(describe):
. Effluent Tee Filterpresent? E] 'Yes ff No, If yes, was i't cleaned? Yes No
5. Observed condition of component pumped:
6. S st r .
Name Vehicle License,Number
Stewart's Sqoic 58 So. Kimball St., BradfordMAi
Company
7. Location where contents were disposed.,
20 S . Mill St., Brqqford, MA
Signature, Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
1
t5 rm 4.doco,11 1 System Pumping record Fags