HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 543 FOREST STREET 1/19/2022 12
Commonwealth of Massachusetts
W City/Town of No. Andover
W° System Pumping Record
Form 4
GM
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.
�tEt'EIVEL.
A. Facility Information
Important:When l BAN 19 2022
fillingthe computer,
1. System Location: �I3 I'L�S7 fH
onnthee computer, -- ANDOVEP
use only the tab OF NOR
key to move your Address HEALT
cursor-do not No. Andover MA
use the return City/Town State Zip Code
key.
2. System Owner:
t� /v l G h(� IVI,
Name— ---
naa
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) [D-S/eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ind'No If yes, was it cleaned? ❑ Yes C5-fda-
5. Observed condition of component p ped:
6. System Pumped B :
Natne Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
Signature of Hauler Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
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