HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 88 ROCKY BROOK ROAD 9/9/2019 (3) Commonwealth of Massachusetts
City/Town of No. Andover
o
System Pumping Record
Y p 9
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,
use only the tab
key to move your Address
cursor-do not No. Andover MA
use the return --
key. City/Town .State Zip Code
2. System Owner:
Name
renen
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - 2. Quantity Pumped: SZ�t7
Date Gallons
3. Component: ❑ Cesspool(s) Yseptic Tank ElTight Tank ElGrease Trap
ElOther(describe): --- ----- --
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
L� 500 S
6. System Pumped By: /}
Name Vehicle License Number
Stewarfs Se tip c 58 So. Kimball St., Brad fo_rd,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
t5form4.doc•11112 System Pumping Record•Page 1 of 1