HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 107 ROCKY BROOK ROAD 9/9/2019 Commonwealth of Massachusetts RECEIVE®
City/Town of No. Andover o ?O'q
DOVER
System Pumping Record TOWN OF DEPARORTH NENT
HEALTH DEPRf�PdEPl7
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
Important:When
filling out forms 1. System Location:
on the computer, 7 p _o I,
1(,
use only the tab 1�n p�y
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record p
1. Date of Pumping Date C1 � r 2. Quantity Pumped: Gallons
) 500
3. Component: ❑ Cesspool(s) Z-Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes DINO If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
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
9- 9 19
of Date
Signature of Receiving Facility(or attach facility receipt) Date
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