HomeMy WebLinkAboutSeptic Tank / Pump Chamber - Septic Pumping Slip - 81 SAW MILL ROAD 8/9/2021 Commonwealth of Massachusetts
City/Town of No. Andover
System Pumping Record RECEIVED
Form 4
Auc o 70?1
DEP has provided this form for use by local Boards of Health. Other form �)hppT4"tdvMhe
information must be substantially the same as that provided here. Befd_,43V`I r #&*WWNZheck with your
local Board of Health to determine the form they use. The System Pumping ecord 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
key to move your Address
cursor-do not 01845
use the return City/Town State Zip Code
key.
2. System Owner:
Name
mrtsn
Address(if different from location)
No. Andover
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe): C ��_kA
4. Effluent Tee Filter present? ❑ Yes [?No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
G)�q-��e rr ���/ .%
6. Syste P umped/
, �.J
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 S ill t.,Bradford,M
4:�;' - C2
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
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