HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 21 CLARK STREET 1/9/2024 QP
Commonwealth of Massachusetts
W City/Town of No.Andover
System Pumping Record �Q
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 vl
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner.-
Name
�e2en
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: Gal ns
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 co dition of component pumped:
C""a
6. System \pe By:
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
DNS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
N City/Town of No. Andover �tioti
System Pumping Record
` 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
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 (L
Name -
I �
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record C5
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 o If yes, was it cleaned? ❑ Yes�o
5. Observed condition of co ponent pump
All of this estimated
information is non-bindi , valid only at the time of pumping. Not responsible beyond the date above.
6. SysteT Pumped By:
0� l(
Name Vehicle License N ber
Company
7. Location where contents were disposed:
Stewart's Receivi acilit , 20 So. Mill St., Bradford, MA 01835
See above
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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