HomeMy WebLinkAboutSludge Tank - Septic Pumping Slip - 351 WILLOW STREET 7/8/2019 (3) luommonwea
Ith of Massachusetts
City/Town of No. Andover,
lot
System Pumping Record
Form 4
DEP has provided this form for use by locall Boards,of Health., Other forms may be used, but the
informiation, 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 loca,l it of Health or other approving authority within, 14 days from the pumping date in
accordance with 310 CM R 15.351.
A, Facility Informaltion
Important:When
filling outforms, 1 System Location,
orfthe computer,
use only the tab
key to,move your Address
cursor-do not No. Andover MA 01845
use the return
key. Cityrrown State Zip Code
2. System Owner:
146'
00 Name
non
Address(if different from[location)
City/Tlown
State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping
2. Quantity Pum ed:
Date Gallons
3. Cl en Cesspool(V3, Septic Tank E] Tight Tank [I Grease Trap
ol
tl /4
(5)V
e0l(describe)-
i co? El No
4. Effluent Tee Filter present? Yes No If yes, was It leaned Yes
5. Observed ondition of component pumped:
R L
6. System, Pumped By:
Name Vehicle License Number
Stewart's S#is,58 So. Kimball St. Bradford
Company
T Location where contents were disposed:
20 So,,.JAi1,1 ,$t, Brqdford,
Signaturei-'of Hauler DatkJ
Signature of Receiving Facility(or attach facility receipt) Date
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