HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1260 OSGOOD STREET 11/3/2022 Commonwealth of Massachusetts REcE�`'�°
City/Town of No.Andover
System Pumping Record p 32022
Form 4 Nov PNpOVE�k
OF14 P wA
DEP has provided this form for use by local Boards of Health. Other formlo ObN 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 Jl v r
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
ray
Name
ream
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 3 2. Quantity Pumped: Gallo is
3. Component: ❑ Cesspool(s) kSeptic 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
�pu ped:
ri
`J
6. Syst Pu ped
Nanie Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 Mill .,Bradfor ,
Signatu of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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