HomeMy WebLinkAboutSludge Tank, Septic Tank, - Septic Pumping Slip - 351 WILLOW STREET 10/4/2023 Commonwealth of Massachusetts
W City/Town of No. Andover
System Pumping Record �42423
Form 4 00�
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
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
Same
Name
seam
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate -- 2. Quantity Pumped: Gallons
3. Co pon t: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe): CS)6/ S� '`'t
4. Effluent Tee Filter present? ❑ Yes M-No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed ndition of component pumped:
�Qp(� All of this estimated
information is non-binding valid only at the time of pumping. Not responsible beyond the date above.
6. System Pumped_15y:
Name Vehicle License Number
Company
7. Location where contents were disposed:
7rr=
ford, MA
See above
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
City/Town of No. Andover
System Pumping Record pit 0
Form 4
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
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
t� �
Same z&k
Name
lento
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �- Z3 --- 2. Quantity Pumped: J -
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
,Other(describe): -
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditions of component pumped:
C/of7)y d All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. Syste umped By:
W—It ---
Nam Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
H W City/Town of No. Andover
W° System Pumping Record �c� ®42023
Form 4
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
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner: n �j
r� Same i / �/
Name ----- ------—--
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dafe - 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- -
4. Effluent Tee Filter present? ❑ Yes [12/No If yes, was it cleaned? ❑ Yes 9-Flo
5. Observed condition of comp o ent pumped:
l� All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Pumped By:
1)
Name Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Receivin Facie, 20 So. Mill St., Bradford, MA
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
H City/Town of No. Andover
a
° System Pumping Record o�j o Z023
Form 4
iG 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 �I W
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
Same
Name
rerun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Ight 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:
All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. Syst Pumped By;�
Nam Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
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Z�-,- Commonwealth of Massachusetts
_ W City/Town of No. Andover
System Pumping Record Cl p4V-1
Form 4
M
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially�'he same as that provided here.Pefore using this form, check with your
local Board of Heal t i'determine the form they use. The Systerrumping Record must be submitted to
the local Board of or other approving authority within 14 dafs from the pumping date in
accordance with 3 15.351.
A. Facility Information
Important:When
filling out forms 1. System Locati
on the computer, gj�� �vl#00) J�—
use only the tab
key to move your Address
cursor-do notuse No. Andover ^"''r :, MA 01845
key.the return City/Town St a Zip Code
2. System Owner:
t� me �uP ' �o
Sa
Name
lCRtl71 R,. �,
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date — 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): / -
4. Effluent Tee Filter present? ❑ Yes 2 No If yes, was it cleaned? ❑ Yes [�No
5. Observed condition of component mped:
All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Pumped By:
-`14 r
Name Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Receiving Facility, So. Mill St., Bradford, MA
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
W City/Town of No. Andover
System Pumping Record 0k?w
Form 4 QC�
G1
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, ' /I J Vkzu
_S�use only the tab �/v_
key to move your Address
cursor-do not No. Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner: f I
tab
Same
Name
gun
Address(if different from location)
-------------------
City/Town State Zip Code
Telephone Number
B. Pumping Record 2
1. Date of Pumping (� ' ZJ 2. Quantity Pumped: a) -
Date Gallons
3. pone t: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes P__No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed dition of component pumped:
&Wr All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Pumpe
Name Vehicle License Number
Company
7. Location where contents were disposed:
Ste al Rec bin F cilit I So. Mill St., Bradford, MA
See above
Si nature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
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Commonwealth f Massach psetts
City/Town of01
System Pumping Record ZM
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. SC stem LOCatIOn:
on the computer, JJ l(, •/, ll04J
use only the tab
key to move your Ad r ss
cursor-do not ( )tqn L ve?Z- MA
use the return
key. City/Town State Zip Code
2. System Owner:
Same,-?a ee
Name -- -- -_._- -- -----
reran,
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 3 2. Quantity Pumped: aeons 0�
3. Compo Scl nt: El El Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe): J41° — '�--
4. Effluent Tee Filter present? ❑ Yes Vl',_No If yes, was it cleaned? ❑ Yes ❑ No
5. Obbs'erved ondition of component pumped:
CC,-"5y All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Pumped
Name Vehicle License Number
Company
7. Location where contents were disposed:
Stew R eivin acilit , Mill St., Bradford, MA 01835
See above ,
ig ature o auler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
a W City/Town of No. Andover
° System Pumping Record ®c� p42o13
Form 4
�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, 3 5-1 WI to o S1
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:rab //✓ / �./9
Same
Name
renm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
9
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
I Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Z�C&e-4 All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. Sys Pumped By:
Na Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Receiving Facility,20 So. Mill St., Bradford, MA
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
w W City/Town of No. Andover
a
System Pumping Record p�� 0 k TO
r` Form 4
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, ?j1 /� 1 ,' I
use only the tab J7_ //t/ (0(w
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
t� Same NJ
Name
�nsn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: 6Q�
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
[Other(describe): i U a g C
4. Effluent Tee Filter present? ❑ Yes E;KNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
I Qo d All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Pumped By:
Na a Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's ReceiviRg Facility, 20 So. Mill St., Bradford, MA
Q V7 See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
City/Town of No. Andover
System Pumping Record p414"
Form 4 Q�
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, 35I I,t ,
use only the tab �/�/ f I
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner: n/
Same
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping oat 2 I Z3 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s El Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe): -�
4. Effluent Tee Filter present? ❑ Yes J:j No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
r""e" All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. S stem Pumped G.
Name Vehicle License Number
Company
7. Location here contents were disposed:
Ste Reppiving Facility, 2 o. Mill St., Bradford, MA `
jal`e See above
Signature of Muler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
City/Town of No. Andover
System Pumping Record j p42��
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,
use only the tab "v
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
re6
Same C _ N r J��/ (0Id
Name -- — --
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D I 6 2-3 2 Quantity Pumped:ate Gallons v� -
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
(Other(describe): S 1'/6).7 e �7njn&L
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
All of this estimated
information is non-bindinj,-vedid only at the time of pumping. Not responsible beyond the date above.
6. Sys m Pumpe
Na a WVehicle License Number
C pany
7. Location where contents were disposed:
Stewart's Receiving Facility' 20 So. Mill St., Bradford, MA
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
�H OE
W City/Town of No. Andover
System Pumping Record Cj 041023
Form 4
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
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
r� ,,/ r
Same G �v o l /Va✓ Vt1
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping g �3 -- Gal
2. Quantity Pumped: ?�da-
Date Ions
3. Component: ❑ Cesspool(s) ❑ Septic Tank ElTight Tank ❑ Grease Trap
[Other(describe): S I V a 9 L
4. Effluent Tee Filter present? ❑ Yes [i No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
9 00A All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Pumped By:
/4 a-ga,()
Name Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA
i!Z DO'S See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
W City/Town of No. Andover
System Pumping Record
2023
Form 4 OCT 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, 3G� w t"
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
Same "
Name
renm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 5 — Z 2. Quantity Pumped: -u0O 6
3. Component: ❑ Cesspool(s) ❑ Septic Tank1 ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): S U C'Ct� n IC
4. Effluent Tee Filter present? ❑ Yes [(No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
900 a All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. System Pumped By:
/MOL. ;On
Name Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Receiving Facility,20 So. Mill St., Bradford, MA
Sd�'1 16-1"Ilt5 See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
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_ Commonwealth of Massachusetts
_ City/Town of No. Andover
o
System Pumping Record
y` 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: ,r
on the computer, ) /•/f 6 w
use only the tab �1�
key to move your Address
cursor-do not No. Andover MA 01845 _
use the return City/Town State Zip Code
key.
2. System Owner:
J
Name
rertm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ' 2 3 2. Quantity Pumped: Gals) v
3. Comp ent: ElCesspool(s) El Septic Tank El Tight Tank ❑ Grease Trap
Other(describe):
C> 1V��7Q
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Cep J�
6. Syst Pumped Z B T ,/
N Vehicle License Number
S art'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
Same day
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
_ uim City/Town of No. Andover Oti3
W System Pumping Record CZ o 4ti
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, 351 V U f'l/u n 'u c
use only the tab 7 LLL J
key to move your Address
cursor-do not No. Andover _ _ MA 01845
use the return City/Town State Zip Code
key.
Z. System Owner:
Name
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping vat r / _3 2. Quantity Pumped: j Gallons G7
3. Component: ❑ Cess ooI(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
ff-Other(describe)
4. Effluent Tee Filter present? ❑ Yes,&—No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed c ndition of component pumped:
C"d
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. M' St. ,Bradt rd, MA
Signature of Hauler Date
Same day
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11112 System Pumping Record•Page 1 of 1