HomeMy WebLinkAboutSludge Tank - Septic Pumping Slip - 351 WILLOW STREET 7/8/2019 (5) CommonwealthofMassachusefts I ff(,/'',,,�,,✓r,/"//! , � ,,,(Af), n/,"""',,,/�, I
City/Town of No. Ando�ver
S�ystem Pumping Record
F orm 4
Af J
DEP has provided this form for,use by local B ,rds of Health,. Other forms may be used, but the
information 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 local Board of Health or other approving authority within 14,days from the pumping date in
accordance with 310 CMS 15.3511.
A. Facility Information
important:When
fi'lling out forms 1 System Location:
on the computer, W//
use only the tab
key to move your Address,
cursor-do not No. Andover MA
use the return
key. City/Town State Zip Code
tab Z System Owner:
Name
.......Add ............................. ——------- .........
ress(if different from to
CitylTown State Zip Code
....................... ........Telephone Number
iig �Relcord
4r
6
1. Date of Pumping, 2. Quantity Pumped:
Date Gallons
I Com hent"(d Cesspool(s 0 Septic Tank 0 Tight Tank F-1 Grease T'rap
--c
ther escribe),*
�4. EffluentTee Filter present.? El Yes -,No,,,. If yes, 'was it cleaned? Ej Yes E] N o,
m P Wt h'
/Nc-
5. Observed condition of compone t pumpe&-
6. St um
.
Vehicle Li ns Number
...................................................................................
,ame cee
Stewart's,.,§�eptiic 58 So. Kim oil St., Bradford,MA
Company
T Location where contents were disposed*
S .o Mill Sti.,, 4adford, MA
�0
Sign, turn of Haulerler
Date
.......................... .....................................n�ature of Receiving Facility(or attach facifity�receipt) Date
t5form4.doco 11/12 System Pumping Record Page I of I