HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 210 RALEIGH TAVERN LANE 11/8/2021 Commonwealth of Massachusetts
W City/Town of No. Andover
a System Pumping Record
Form 4
GSM
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, Z�b '
use only the tab a e(�, fi tf-ern H2
key to move your Address
cursor-do not No. Andover _ MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
co
Lo I I
Name - ----
ienem
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record //S
1. Date of Pum in - C� 1 -� 2 uantit Pum ed: (i�/�
p g Date y p Gallon
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — ---- — - -----
4. Effluent Tee Filter present? ❑ Yes VNZo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compone mped: /
6. ,,8yFerRPumped By:
1 '-zo
Name Vehicle License Number
P/1-
Stewart's Septic 58 So. Kimball St., Bradford,MA
'--/
Company
7. Location where contents were di
20 So. St., Bradf , A
gna ure o Date
Signature of Receiving Facility(or attach facility receipt) Date
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