HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 11/6/2019 (5) 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 ate in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When Z 6
filling out forms 1. System Locatio
on the computer,use only the tab V� '/ �` C
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key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. Syst. O
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Name
rim
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 9 — 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) 0 Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ET/No If yes, was it cleaned? ❑ Yes [3/No
5. Observed condition of component pump J-1
'� �✓
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, Brad rd, MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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