HomeMy WebLinkAbout- Septic Pumping Slip - 71 PADDOCK LANE 2/7/2020 RECEIVED
Commonwealth of Massachusetts FEB 0 7 2020
W City/Town of No. Andover TO�NNOF NOW HANDOVER
System Pumping Record HEALT14DEPARTMEN7
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
Important:When
filling out forms 1. System Local , n: l /
on the computer, Li % _,�iIO ct G,n
use only the tab Lit �G(tiU
key to move your Address
cursor-do not No. Andover MA 01845
use the return
City/Town State Zip Code
key.
r�
2. Sys te wner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date�, 2. Quantity Pumped: Gallons
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 lcondition of component pumped:
6 ? 6r
6. System Pumped By:
CKJU _
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
Signature of HaulWr Date
Signature of Receiving Facility(or attach facility receipt) Date
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