HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1515 SALEM STREET 6/22/2020 or-CEIV Eu
Commonwealth of Massachusetts 1UN 2 2 OL'.''
�1 W City/Town of No. Andover 'Too H �140FIHPTMENT R
a W° System Pumping Record
Form 4
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: �1 AM
on the computer,use only the tab �.�Gf U
key to move your Address T
cursor-do not No. Andover MA 01845
use the return —
key. City/Town State Zip Code
2. System Owner: `�
Name
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
S'- (3- 00 1 0 0
1. Date of Pumping Date 2. ritity Pumped: Gallon
3. Component: ElCesspool(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 condition of component pump
Z(---
6. System Pin
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents di ed:
-S Mr t., Bradford;were 2
ignatur m;a.. Date
Signature of lq4ceiving Facility(or attach facility receipt) Date
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