HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 170 OLYMPIC LANE 9/9/2019 Commonwealth of Massachusetts
W City/Town of No. Andover
System Pumping Record
Form 4
M
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 �ow�oF\AU J- Cc�
Important: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 01845
ke City/Town State Zip Code
Y
2. System Owner:
Wo fit,
Name
rznen
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record d— ) 000
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight 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. �m Pumped By:
Namej 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
F- E- 19
Sf of au er Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112 System Pumping Record•Page 1 of 1