HomeMy WebLinkAboutSeptic Pumping Slip - 165 Mill Rd - Septic Pumping Slip - 165 MILL ROAD 9/30/2024 Commonwealth of Massachusetts
City/Town of No Andover
- w System Pumping Record
4 K
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: °
an the computer, y •
use only the tab
key to move your Address
cursor-do not
use the return --- _...__. ..__.. ................. ........ ............................ ------........-........................... .. ....- _. _ _..........
.........___--__.
key. City/Town State Zip Code
VQ 2. System Owner:
Name
reiran
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: Gallons
3. Component: [.] Cesspool(s) _. septic Tank [._,..[ Tight Tank Ej Grease Trap
Other(describe): --
4. Effluent Tee Filter present? ( ] Ye - , No If yes, was it cleaned? [_..] Yes ] No
5. Observed condition of component pumped:
6. e Pumped By:
Name Vehicle License Number
Stewart's Se ptic 58 So Kimball St. , Bradford,MA
Company --
7. Location where contents were disposed:
20 So.Mill 51.,Bradford,MA _
A
Signature of Hauler "" Date - -
Signature of Receiving Facility(or attach facility receipt) Date
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