HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 279 BOXFORD STREET 7/8/2019 Ip�IN III/
ulowlmonweait
of' 11101assachusetts,
'
City/Town of
Andover
h No. if
System
I
b 9
Pumping Record
OF
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be, used, but the
i information must be substantially the same as that provided here. Before using this form, checkwith your
local' r Health to etermin the form they use. The System Pumping Record rust bel submitted t
the local Board of Health or other approving authority within 14, daysfrolm the urrr ping date I
accordance with 310 CMR 15.35 11 P
A. Facility Information
Important-When
on the computer,
filling out forms 1. System Location:
r
use only the t ' Z, 214
key to move your address
cursor-do not
No. Andover MA 0,1845
use the return City/Town State Zip Code
2, System Owner:
1
Name,
Address(if different from location)
City/Town State Zip Coda of
Telephone Number
B. Pumpling Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component', Cesspool(s) Septic Tank El Tight Tank, El Grease Trap
Other (describe):
4. Effluent Tee Filter presents El Yes I' If yes, was it cleaned Yes 0, N
51. Observed condition of component, r w
a
o "
6. dump y*
0
e rr Vehicle License Numbelr
Stewart's septic 58 So., Ki St, Bradford,MA
Company
7. Location where contents were ispose -
2 $6, Mill radford, MA
Signature of IHauler Z Date
Signature f Receiving Facility r attach,facility receipt), late
i
1
t5f rm . o 11/12 Sy t rn Pumping Record Page 1 of