HomeMy WebLinkAboutSludge tank & Lift Station - Septic Pumping Slip - 351 WILLOW STREET 10/7/2019 Commonwealth of Massachusetts
W City/Town of No. Andover
System Pumping Record
Form 4
'GSM
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 p� Z
Important:When
filling
computer,
1. System Location:
o
use only the tab
key to move your Address
cursor-do not No. Andover MA
use the return
key. City/Town State Zip Code
�11 2. System Owner:
V &�e `AJ ' -J m y
Name
Address(if different from location)
City/Town State Zip Code
Telephone Nymber
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons r
3. Com nent: ❑ Cesspool(s) ❑ Septic Tank [:1Tight Tank ❑ Grease Trap
Other(describe): ``lam � z
4. Effluent Tee Filter present? ❑ Yes (�INo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped: //
k l `
6. System Pumped By:
J r�l
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Brad_ford,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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