HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 ABBOTT STREET 9/9/2019 Commonwealth of Massachusetts �`'�`�
W City/Town of No. Andover System Pumping Record �.Oy,4NOFNOI:UHANOOvER
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Form 4 h�F,LTH OEFARTMENT
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, 25 fj�� ( � Sfi use only the tab �dp 7
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
� �! a j --- J'oe
Name
Horn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Y4 1 C c y
p g Date 2. Quantity Pumped: —
Gallons
3. Component: ❑ Cesspool(s) Z Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2/No 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., Bra rd, MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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