HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 378 SALEM STREET 8/4/2023 Commonwealth of Massachusetts
W City/Town of No. Andover
System Pumping Record
Form 4 1
',M 1
DEP has provided this form for use by local Boards of Health. Other for s may be used, but the
information must be substantially the same as that provided here. Befor using this form, check with your
local Board of Health to determine the form they use. The System P 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 Q J
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
fe(41 �rz
Name
rattm
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B.Pumping Record
1. Date of Pumping Date / 2. Quantity Pumped: Ca11ns
3. Component: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes to If yes, as it cleaned? ❑ Yes ❑ No
5. Observed condition of component pump
6. SysteMP_=Ded Rv
Name Vehicle License Number
Stewart's Septic 58 So KuMall 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
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