HomeMy WebLinkAboutSeptic Pumping Slip - 15 Long Pasture Rd 10-23-24 - Septic Pumping Slip - 15 LONG PASTURE ROAD 10/23/2024 Commonwealth of Massachusetts
City/Town of No Andover
System Pumping Record
4
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 m^J
use only tab ing out forms 1. System Location: �w
on the computer,
y
key to move your Address
cursor-do not
usethe return - -... .......-_------------------------------— _._........._....__. _...._._................_....-- _.._._.._............_.....-----.--......................._.-
key. City/Town State Zip Code
2. System Owner: �.
Name
arum
..____......_......_----
Address(if different from location)
No Andover MA
City/Town State Zip Code
B. Pumping Record _-
Telephone Number
1. Date of Pumping Date % 2. Quantity Pumped: " —
Gal oK s
3. Component: Cesspool(s) -_ Septic Tank [ Tight Tank Grease Trap
r
❑ Other(describe): — /No
4. Effluent Tee Filter present? [-1 Yes J__._ If yes, was it cleaned? Yes [,j No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic 158 Sa Kimball St. , Bradford,MA
Company _
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
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