HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 566 FOREST STREET 5/19/2020 1C-N_ Commonwealth of Massachusetts
W City/Town of No. Andover
System Pumping Record
` 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 Location:
on the computer, 5_
use only the tab (? �f"
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner: J
Name — ----
�un
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. tity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) eptic 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:
�C)6<> C_/
6. System PV By: I
/_��
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were dis osed:
�20 So. Mill Bradford, MA
nature o4faul Date
Signature of iving Facility(or attach facility receipt) Date
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