HomeMy WebLinkAboutSeptic Pumping Slip - 265 Haymeadow - Septic Pumping Slip - 265 HAY MEADOW ROAD 10/4/2024 Commonwealth of Massachusetts
M _
City/Town of No Andover
a.
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
a.
cursor-do not
usethe return _.�._..____....�.._____......._......____._................_ _._..._____._--.._..._........_..
key. City/Town State Zip Code
2. System Owner:
VQ
Name )
Address(if different from location) —
No.Andover _ MA
City/Town State Zip Code
Telephone Number —
_ B. Pumping
��....�..�.�.,._ ._._._
Re cord
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 [ No If yes, was�itcleaned? [.f Yes [, ,_ No
5. Observed condition of component pumped:
6. Sy,�s„tem Pumped 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
of Receiving Facil ity(or attach facility receipt) Date
Signature
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