HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 132 DUNCAN DRIVE 8/6/2019 Commonwealth'of Massachusetts RECENED
City/Town of No. Andover AUG 0 6 201
System Pumping Record TCONNOF NORTH ANbUVER
0 Form 4 WEALTH 111AR7MIN7
DEP has provided this form 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 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 CMR 15.351.
A. Facility Information ,
Important:When/ j
filling out forms 1. System Location:
on the computer, /22 _Ajfica,
use only the tab ./ /J
key to move your Address
cursor-do not No. Andover MA
use the return key. City/Town State Zip Code
2. System Owner:
t� vi%/f`I
Name ((PVC /
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record p
1. Date of Pumping Date o /0— 2• Quantity Pumped: Gall ns0 0
3. Component: ❑ Cesspool(s) 2r"Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [Z/No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Ekce5[\1e S I c s 0
6. System Pumped By:
Name �.J Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA q
S' a uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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