HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 240 RALEIGH TAVERN LANE 11/23/2020 Commonwealth of Massachusetts
City/Town of No. Andover RECEIVED
7
° System Pumping Record NOV 213 2020
Form 4
w„ ?owEALTN DEPAR7MENT�
DEP has provided this form for use by local Boards of Health. Other forris 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,
use only the tab ��' 111 l F-Z;
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
�ll 2. System Owner:
Name -------
�n
Address(if different from location)
1
City/Town State Zip Code
Telephone Number
B. Pumping Record
to .Z � S��
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Ua
6. System Pumped By:
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
1
Signa of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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