HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 467 SALEM STREET 8/3/2022 Commonwealth of Massachusetts PUG o 3 V11
City/Town of No.And wer N�R�"�P"ENS
a System Pumping Record pWNo�µ0�_PPBT
Form 4 taEP
^ M 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,
use only the tab Address
key to move your
cursor-rio not Zip Code
use the return City/Town State
key.
2. System Owner:
Q
Name
team,
Address(if different from location)
No.Andover MA
State Zip Code
City/Town
Telephone Number
B. Pumping Record
DO
1. Date of Pumping Date
2. Quantity Pumped: Gallons
)
3. Component: s _j'Septic Tank ❑ Tight Tank El Grease Trap
❑ Cesspool(s)ool p (
❑ Other(describe):
4. Effluent Tee Filter present? ❑ YesgNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. S Pumped By:
Vehicle License Number
Name
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
_OUGl
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record•Page 1 of 1
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