HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 CRICKET LANE 11/12/2013 Commonwealth of Massachusetts
W City/Town of No Andover
System Pumping Record
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 a{
Important:When VOW 1 2 2013
filling out forms 1. System Location:
on the computer, TOWN Ut iv: i t'Ci s ANDOVEF2
use only the tab lo cocw4 I n e-
key to move your Address
cursor-do not No Andover Ma
key the return City/Town State Zip Code
Y�
00-71 2. System Owner:
Y2L�l Hal
Name
reRun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 1 6 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: 1 .
6. stem Pumped By:
r.NO
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
ignature of Ha -- -- Date
Signature Receiving Facility Date
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