HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 234 BRIDGES LANE 7/8/2019 Commonwealth of Massachusetts
" a"`W
o4l, 61
Cilty/'Town of No., Andover
wa
System, Pumpling Record
Form, 4
DEP has provided this formi for use by local Boards,of Health., Other forms may be used, but the
information must be substantially the same as that provided here. Before using this lorm, �check with your
local Board of Health to determine the form they use. The System Pumping, Record must be submitted to
the local Board of Health oir other approving authority with�in 14 days from the pumping date in
accordance with 311 01 CM R 15,351.
A. Facility Iant"
Implortant-,When
filling out forms 1. System Location-,
on the computer,
use only the tab
key to move your Address
cursor-do not
No. Andover MA
use,the return
key. City/Town State Zip Code
2. System Owner:
tab
Name, 6ove,
Address(if different from location)
City/Town State Zip Code
Telephone,Number
B. Pumping Record
6,
1., Date of Pumping Date 2. Quantity Pumped:
3. Component: Cesspool(s,) Septic Tank Tight an El Grease Trap
Other(describe)-
4,. Effluent Tee Filter present? El Yes, El No If yes, was it cleaned? Ej Yes
5. Observed condition of comp�onen't purn ped* '001
6. System Pumped By:
Name Vehicle License Numbiler
'Stewa rt's Septic 58 So. Kimball, St.) BradfordMA
Company,
7. Location where contents were disposed:
20 S . Mill St., Bradford, MA
..........-
Signature of'Ha,uler Date
.............
Signature of Receivinig Facility(or attach f'acility recelpt) Date
t5f 1/12
,System Pumping Record Page I of 1