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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 89 CHRISTIAN WAY 4/20/2022 Commonwealth of Massachusetts ti 1°tit City/Town of No Andover pQR 0 ' - System Pumping Record NOPJJAN;-VR Form 4 10 NA 0"NOes> R'a 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 f filling out forms 1. System Location: j on the computer, 5C 1 use only the tab CJ key to move your Address cursor-do not use the return Citylfown State ; Zip Code key. 2. System Owner: A���z� _ Name -- renm Address(if different from location) No Andover MA City/Town State Zip Code Telephone Nu ber B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons i 3. Component: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes u No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: g0©�! 6. System Pumped By: A'az 3 d Name 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 Signature of Receiving Facility(or attach facility receipt) Date ------------------------------- t5fomt4.doc• 11/12 System Pumping Record•Page 1 of 1