HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 23 SULLIVAN STREET 11/6/2019 IL
Commonwealth of Massachusetts
City/Town of No. Andover
° 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
Important:When
filling out forms 1. Syste 6atlon:
on the computer,
use only the tab 1
key to move your �ddre s
cursor-do not . Andoye
use the return MA
key. City/Town State Zip Code
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2. System Owner:
'�_s .SL�,I
Name
renm
Address(if different from location)
City/Town State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
.0- }I Oo
Date 2. Quantity Pumped:
Gallons L-
3. Component: ❑ 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. Observed condition of component pumped:
0 0
6. System Pumped By:
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
49Ci�6 a--,1-d 4e,5 Date
(ti hq
Signature of Receiving Facility(or attach facility receipt) Date
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