HomeMy WebLinkAbout- Septic Pumping Slip - 147 JOHNNY CAKE STREET 7/8/2019 Ilan
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System Pumping Record
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Form 4
DEP has provided this fora for use by local Boards of Health. Other forms may be used, but the
information rust substantially the same as that provided here., Before using this fora, check with your
local Board of Healthto determine the form,they use, The System Pumping Record must be submitted t
the local Board of Health or,other approving authority within 14 days from the pumping date in
accordance with 310 CMR15.351-
A. '
Facility Information
Important;When
filling out forms 1. System Location:
on the computer, 54"
use only the tab
Ivey to move your Address
cursor-do not . Andover MA 0 1 5
use the return ..
key. City/Town State Zip Code
tab
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Cade
Telephone Number
BI.
Pumping Record
1.
Date Pumping �. ���.. �.��ri�. � .����:,,: � 2. Quantity Pumped:
Gallons
3. Component: Cesspool(s) W 6 ptic Tare El Tight Tank Grease Trap
El Other (describe):
. Eftiuent Tee Filter present? El Yes NIA If yes, was it,cleaned` es N
5. Observed condition of component pumped:
6. System F m By
Name Vehicle License Number
Stewart's Septic,58 Sow Kimball St,, BradfordJMA
Company
T. Location where contents were disposed,*
2 , S . Milltr r drd
u.:.„ . ... .. �m
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f
Signature Receiving Facility r attach facility receipt) 'Date
t5form4.docs 11112 System Pumping pin Record Page 1 of I