HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 350 HOLT ROAD 4/20/2022 Commonwealth of Massachusetts
( City/Town of No.Andover ApR 2 �202 ovER
System Pumping Record oF t��RpPA MENT
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:
on the computer, �7�
use only the tab f�
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
CMsaA#_41- P&OZE
Name —
meen
Address(if different from location)
No. Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1
1. Date of Pumping Date uantity Pumped:
Gfffloni�
3. Component: ❑ Cesspool(s) ���eTpticank ❑ 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:
G�
6. Syste mped By: I � 3S
'�-
Na Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Locatm where contents were disposed:.
20 o.Mill St., radford,MA
l� F
auler Date—
Signature of Receivfng Facility(or attach facility receipt) Date
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