HomeMy WebLinkAbout- Septic Pumping Slip - 247 FOREST STREET 7/8/2019 I r p, wnJ
%r 4'�'[ WJIiWi,9 l i2/ir
Commonwealth of Massachusetts
,mm
City/Town of No. AndoverSystem Pumpling Record'
�
{
TUP/N 0 00
n
0 1 !Form 4
d'
lfl GG
DEP has provided this ford for use by local Boards of Health. Olth r forms may be used,, but the
information rust 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 t
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15,351.
X Facility Information
Important When
filling out forms 1. System Loc atibn,
on the computer,
use only the tab
key to moveyour Address
cursor-do not No. Andover MA
use the return
CIt /Tvn State Zip '
2. Bataan Owner,
Name
reArn
Address if different from location) 1
.m m. .., . n...mm .... .....,.. ..., �,,,,,,M.,. , .. ...
City[Town Stag Zip Code
Telephone Darr
131. Pumping Record
1. Date of'Pumping 2. Quantity Porn
Date Gila
N.
3. Component: C �s,s 1 s Septic Teak El Tight Tank El Grease Tr
El Other(describe):
4. Effluent Tee Filter present? E] Yes 0 No If yes, was it cleaned? Yes El, No
5. Ohiser �ed raidit�i �n of component raped- a
Ile
'02"t , I
6. System u ,
Name Vehicle License Number
stew rt's Septic 58 So, Kimball St, Bradford,MA
Company
7. Location where contents were disposed'.
r
20 Say,. l li'll' St., Bradford,, MA
C
ll
Signature f Hauler Cate
Signature of Receiving Facility r attach facility receipt)t Date
t5f rwr . ce 11/12 System Pumping,Record Page 1 of 1