HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 71 CANDLESTICK ROAD 9/8/2020 Co
mmonwealth of Massachusetts RECENED
City/Town of No. Andover Sip 0 8 2020
u f TH ANDOVER
OF NOR
System Pumping Record T�H�LTHOEFARTMENT
Form 4
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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:
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on the computer,
use only the tab C"(r
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
Name —
enm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
Ale
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes 4 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component umped:
6. System Pumped By:
NarrTe Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., BraAfo—V MA
�i3f
Signs ure o Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11112 System Pumping Record•Page 1 of 1
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