HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 310 BERRY STREET 5/19/2020 IL
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 date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System LoczZon:
on the computer, 7 /0 � _(( Q�
use only the tab J � �1u --
key to move your Address
cursor-do not No. Andover MA 01845
use the return Citylrown State Zip Code
key.
2. System Owner:
Al-42rm
Name —-- -- - ---- --- ----
Address(if different from location)
City/town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date �C12. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes F2�No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of co onent pumped:
"Ilea S 1, 7-5 Url
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 Sq. 0$1 ., Bra rd, M
Si ature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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