HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 125 ROCKY BROOK ROAD 12/7/2020 Commonwealth of Massachusetts RECEIVE®
City/Town of No. Andover n ^ n 7 2020
System Pumping Record
� `N ANDOVER
4cwM Form 4 ,RTMENT
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,
use only the tab 1Qa 5Q w&, e _
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System
/�Owner:
fg
Name r —-
gun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Q ntity Pumped: Gauo s
3. Component: ❑ Cesspool(s) ��epticTank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? El Yes �Olf yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component roped:
6. Syste um ed By:
Name Vehicle License Nu/tuber
Stewart's Septic 58 So. Kimball St., Bradford MA
Company
7. Location where contents were disposed:
2 Mill St., radford, MAi-
b�7
Signatur Date
Signature of Rec ' ing Facility(or attach facility receipt) Date
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