HomeMy WebLinkAbout- Septic Pumping Slip - 351 WILLOW STREET 6/10/2019 (8) Commonwealth of Massachusetts
City/Town o., Andover
System Pumping Record
V
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 114 days from,the pumping date in
accordance with, 310 CMIR 15.351.
,A. Facility Information
Important-When
filling out forms 1. System Location:,
on the computer,
use only the tab
key to move your Aiddress,
cursor ,-do not
No. Andover MA 0 1 84�5
use the return City/Town State Zip Code
key.
tab 2. System Owner-,
........
Name
Address(if different from location)
City/Town State Zip Col de
Telephone Number
B. Pumping Record
2. Quantity Pumped:
1 Date of Pum pi ng Date Gallons
3. Component: Cesspool(s) Septic Tank [�J�Tight Tank El Grease Trap
01 Other(describe),,
4. Effluent Tee Filter present? E] Yes E] N o If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
4CA11
6. System Pumped By:
Niame! Vend e License Number
Stewart, ti
p§, c 58 So. Kimball St., Blaoford,,IVIA
Company
7. Location where contents were disposed,
20 So. Mill St., Bradford, MA
..........
nature of Hauler Date
...............
Signature of Receiving Facility(or attach facility receipt) Date
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