HomeMy WebLinkAbout- Septic Pumping Slip - 33 SHERWOOD DRIVE 5/8/2019 Coll I III I IUI Mt:Iellith of' Massachusetts
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Form 4
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DEP 1
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has provided thi's 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 fora, check with your
local Board of Health to,determine the form they use, The System Pumping Record mast be submitted t;
the local. Board of Health r other approving authority within 14 days from the pumping, date, in
accordance with 310 CMR 15.351,
A. Facility Inf
Import un :When
filling out forms 1. System Location:
on the computer,
use on,ly the tabi
key to move your Address
cursor not 1 . Andover
usethe return City/Town . . .,,., ..� ...w u..�,.. .
key,
StateZip Code
2. System Owner:
VQ o m el",
Naas
Run
Address(if different from location)
City/Town 'State Zip Code
Telephone Number
'3B, Pumping Record
1. Date of Pumping ._®. 2. Quantity Pumped: .. .
Nit 11on
I Component: C sspa l s Septic Tank Tight'fan Grease Trap
El Other(describe):
n Effluent Tee Filter present? El Yes It yes, was it cleaned? Yes No
i
51. Observed condition component 'r �ocd
p
. System umped By*,
Name Vehicle License Nurnbeir
Stewart's Septic 58 So. Kimball, St., Bradt rd,M' .
-Company
7. Location,where contents were disposed:
20 S . Mill Sit., dtrdMA
r
u afjT6 r Date
Signature f Receiving Facility r attach facility receipt) Date
t5form4.doice 11/12 S St M PLIM�ping Record Page 1 of 1