HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 231 FOREST STREET 10/7/2019 Commonwealth of Massachusetts
W City/Town of No. Andover
o System Pumping Record
Form 4
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 0,�� 0LVA
v�ER
Important:When
filling out forms 1. System Location:
on the computer,
use only thehe tabtab
key to move your Address
cursor-do not No. Andover MA
use the return -
key. City/Town State Zip Code
2. System Owner:
Name
ream
Address(if different from location)
City/Town State Zip Code
03 b 301 2
Telephone Number
B. Pumping Record ze
1. Date of Pumping Da---0 te 2. Quantity Pumped: Gallons
3. Component: ElCesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --.-
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componenypmped.
6`
6. System Plimped By:
dfi�pj 4&� --- - -
0A Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., adford, A
Sig ature of Hauler Date
ignature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11112 System Pumping Record•Page 1 of 1