HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 21 CLARK STREET 10/4/2023 Commonwealth of Massachusetts
u W City/Town of No. Andover
System Pumping Record Q�t ti�ti��3
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, 2
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:
rah
1% c .S
Name 6
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
23
1. Date of Pumping -- 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) �ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Y No If yes, was it cleaned? ❑ Y No
5. Observed ✓ ion of component um ed:
v
6. Syste mped By:
Name Vehicle Liclnse Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
2 ra
nature of Hauler Date
_ Same day
Signature of Receiving Facility(or attach facility receipt) Date
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