HomeMy WebLinkAboutSeptic Pumping Slip - 114 Lacy St - 10-14-2024 - Septic Pumping Slip - 114 LACY STREET 10/14/2024 Commonwealth of Massachusetts
w City/Town of No Andover
System Pumping Record
e 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 ° - � � r "
key to move your Address
cursor-do not
usethe return ___._.._. _..........------_----_ _.. ____ ____— _.._._...__. ____.--- _............._..—
key. City/Town State Zip Code
2. System Owner:VQ -
Name __�"
ranan
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: Ilons
3. Component: ) Cesspool(s) eptic Tank [_..p] Tight Tank Grease Trap
[� Other(describe):
4. Effluent Tee Filter present? [_[ Yes No If yes,was it cleaned? (_ ] Yes No
5. Observed condition of component pumped:
6. System P mped y: l
9
Name Vehicle License Number
Stewart's Sep is 58 So Kimball St. ,Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill S dford,M
ure of H Date
--...__� _ ------........
__._ �..__.._.._ _... --._..._.__............_.—_.
Signature of Receiving Facility(or attach facility receipt) Date
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