HomeMy WebLinkAboutDynamic Waste - Septic Pumping Slip - 21 CLARK STREET 12/19/2024 Town Of IVOtth Andover
Commonwealth of Massachusetts
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City/Town of No Andover 025
System Pumping Record
H
Form 4 entryDepcIrtMent
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 CIVIR 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 --—------
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
No Andover MA
City/Town State Zip Code
B. Pumping Record
1. Date of Pumping — a'Dte 2. Quantity Pumped: Gallons
3. Component: �eptic Tank Grease Trap
Cesspool(s) Tight Tank
F] Other(describe):
4. Effluent Tee Filter present? Yes, No If yes, was it cleaned? Yes No
5. Observed condition of com onent pumped:
6. S umped By:
Name------,' Vehicle License Number
Stewart's Sept
ic§§ So tCimball St. , ILradfordIVIA
Company
7. Location where contents were disposed:
20 o.Mill St.,Bradford,MA
signatuVeof Hauler Date
Signature of-Receiving Faciiity(or attach fac-itity receipt) Date
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