HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 46 OXBOW CIRCLE 8/6/2019 J ,
Commonwealth of Massachusetts
City/Town of No. Andover ���U
System Pumping Record AUG 0 0 1019
Form 4 ci-NOpllrl ANDOVER
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. Befor-e 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
filling out forms 1. System Location:
on the computer, 1, 86r6k) C
use only the tab vC
key to move your Address
cursor-do not No. Andover MA
use the return key. City/Town State Zip Code
�1 2. System Owner:
Name
tenon
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
--B. Pumping Record
1. Date of Pumping Date ~�Z ` 2. Quantity Pumped: (
Ilona
3. Component: ❑ Cesspool(s) L� Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Er"No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:6. System Pumped By:
Dame 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
��Z-
S2gnaturAfV Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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