HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1030 FOREST STREET 12/13/2021 Commonwealth of Massachusetts
W City/Town of No. Andover
System Pumping Record
iv^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 out forms 1. System Location: c
on the computer, l 0 2_'use only the tab �U
key to move your Address
cursor-do not No. Andover _ MA 01845
use the return key. Cityrrown State Zip Code
2. System Owner:
Name
ieRm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
�
1. Date of Pumping gate / 12 - � ( - 2 uantity Pumped: gallons I
3. Component: ElCesspool(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:
-- �za QC.
6. Sy _ mped By:
I _ �n _ /
Y �
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were dispo
20 5o. Mil t., Bradf d, MA / n
Si natur of er Date
Signature f Re ' ing Facility(or attach facility receipt) Date
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