HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 975 FOREST STREET 9/7/2021 N: Commonwealth of Massachusetts
? City/Town of No. Andover R -CEIV'EO
r System Pumping Record 0
3 V
i` Form 4
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DEP has provided this form for use by local Boards of Health. Other forms may �d`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: rC-
9on the computer, ,
use only the tab
key to move your Address
cursor-do not 01845
use the return key. City/Town State Zip Code
2. System Owner:
P- ZI-bel�
Name
ream
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) �k 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 pumped: Gco—c)
6. System Pumped By:
�O�
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 . ill St.,Bradford,MA
Signat of Hadler Date
Signature of Receiving Facility(or attach facility receipt) Date
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