HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1234 SALEM STREET 11/8/2021 Commonwealth of Massachusetts
W City/Town of No Andover
a System Pumping Record
iG M
Form 4
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 ou'forms 1. System Location:
on the computer,
use only the tab c 1 V t
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
Name
rertan
Address(if different from location)
No Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2—` 500
2. Quantity Pumped. Gallons
3. Component: ❑ Cesspool(s) 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: Cl=
6. Syste mped By:
��
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So. WII St.,Bradford,MA
Signatur&rdf'r-iau_Ti5r Date
Signature of Receiving Facility(or attach facility receipt) Date
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