HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 717 FOSTER STREET 7/8/2019 I 11R, 11111�10
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Ci ty/Town of No. Andover
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System ,pump'lmn,ig Record
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Form 4 'kiLl I -,","'J,
DEP has prodded this form for use by local Boards of Health. Other forms may be s,ed, but the
information must be substantially the same as that provided here. Before using this,form, check with your
locI l Board of Health Idetermine 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. Facil"11"'Ity Informalfion
Important:When
filling out forms 1 System Location:
on'the computer,
use only the tab
key to imolve your Address
cursor-do not Not Andover MA
use the return City/Town 01845
key. State Zip Code
2. System Owne,r:
n
Name
Address(if different from location)
C�ity/Town
State Zip Code
'Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallon,s
3. Component: E] cesspool(s) peptic Tank El Tight Tank Ej Grease'Trap
D Other(describe)*
4. Effluent Tee Filter present? E] Yes If yes,, was it cleaneld? El Yes [I No
5. Observed ondition of component pumpe
6.
"em Pumped,
:>
Name Vehicle License Numbe�r
Stewart's Septic 518 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
2P S . Mill St., ra�df M A
...........
er
, ,adf
S. nature of Hauler Date
Signature,of Receiving Facility r attach facility receipt) Date
t5form4.do,c*11/12 System Pumping Recordo Page I of 1