HomeMy WebLinkAboutEQ Tank - Septic Pumping Slip - 351 WILLOW STREET 8/6/2019 Commonwealth of Massachusetts rEgu
w City/Town of. No. Andover Q01q
System Pumping Record - 4 AUG
Form 4 - ,OV40 OF{TORT;;ANDOvEP
,ITN DER�nCPf,ENT
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 31`0 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,use only the tab �� Rh,IJ of 1 S�—
key to move your Address
cursor-do not No. Andover MA
use the return key. City/Town State Zip Code
2. System Owner:
t� A T®
,Name .
renrm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record q
1. Date of Pumping Dater Z3 ' / 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank 6q 'Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By- /- \ 3(
& t m(�e_
Name 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
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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