HomeMy WebLinkAbout- Septic Pumping Slip - 21 CLARK STREET 6/10/2019 Commonwealth of Massachusetts
RECEIVED
e _r
City/Town of No. Andover
Sy,stem PumOnlg Relcord
Form 4
'TOW,4,OF�AORTJ1/\INIDOVEEI""',
N171'
DE,P 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
filfing out forms 1. System, Location:
on the cornputer,
use only the tab -------------------- .........
key to solve YOUr Address
cursor-do not No. Andover MA 01845
use the return
City/Town State Zip Code
key.
2. System Owner.-
tab
Name
.Ad ..............dress(if different from locat�ion)
City/Town State Zip Code
Telephone Number
Bi. Pumping Record
1. Date of Pumping CL 2. Quantity Pumped: 0
Date Gallons
3. Component: Clesspool(s �Septic Tank E] Tight Tank [_1 Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Yes If yes, was cleaned? Yes No
5. Observed condition of component pumped:
............. ......
6. System Pumped By:
--k( ............ ......
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St, BradfordIVIA
Company
7. Location where,contents were disposed-,
20 So. Mill St., Bradford, MA
Irv,
.......... ------
S i g4n a t u ref� auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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