HomeMy WebLinkAboutSepitc Tank - Septic Pumping Slip - 351 WILLOW STREET 2/7/2020 Commonwealth of Massachusetts RECEIVE®
City/Town of No. Andover FEg p 7 ��
System Pumping Record TowNOFNORI RZMENER
Form 4 VO-1IHt)EPA T
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
Important:When
filling out forms 1. System Location:
on the computer, 35 r WI �I��f S�-
use only the tab
key to move your Address
cursor-do not NO. Andover _ MA
use the return City/Town State Zip Code
key.
2. System Owner:
Name--
renen
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record _
1. Date of Pumping Datef l ��' �� 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) tK Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — —
4. Effluent Tee Filter present? ❑ Yes UYNo If yes, was it cleaned? ❑ Yes Er"No
5. Observed condition of compor}ent pumped:
6. System Pumped By:
ro
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 Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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