HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 190 GRANVILLE LANE 9/9/2019 l
1�2N Commonwealth of Massachusetts '
3. W City/Town of No. Andover ' ,F'� tP�,p
System Pumping Record -��, p t1 A`'
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Form 4
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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, J (9kan tI% //e
use only the tab 116
key to move your Address
cursor-do not No. Andover MA
use the return
key. City/Town State Zip Code
2. System Owner:
Name
renm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record /
1. Date of Pumping Date ^ ( '�— 2. Quantity Pumped: f 660
Gallons
3. Component: ❑ Cesspool(s) $Septic Tank El Tight Tank El Grease Trap
El Other(describe): 44,
`
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pump
6. System Pumped By: cnn
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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