HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 119 DUNCAN DRIVE 6/4/2024 �A,i`�.,., : .i
Commonwealth of Massachusetts
City/Town of No Andover JUN 0 4 2024
.� 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
use the return City/Town State Zip Code
key.
2. System Owner:
Name
nanr
Address(if different from location)
No Andover MA
Cityfrown State Zip Code
Telephone Number
B. Pumping Record 15DO
1. Date of Pumping Dat 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s)�eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes-IseNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Q�2-0
13
6. Syste _ped 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
Signature of Hauler Date
Signature or Receiving Fatality(or attacn ratality receipt) oate
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