HomeMy WebLinkAboutSeptic Pumping Slip - 149 SUMMER STREET 8/10/2015 ^ ^ ^
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City/Town `�/ x�[)x �o / Andover
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System Pumping Record
Form 4 TO�NCFMOn�HxMODVER
`���a� HEALTHD�F�RTN�NT
DEP has provided this form for use by local Boards ofHealth, Other forms may be uaed, butthe
information must be substantially the same mathat 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 31OCyWR15.851 �
� �
A~ Facility Information �
Important:When ,
filling out forms 1. System Location:
on the computer,
use only metab
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key m move your Address ----- ----- --
cursor-uunm
North ----____- ---�'--.._ ' --'___-___-_-'--- -------------'----
key, ^.w`.°°n State Zip Code
2. System Owner:
wame ~�/ ��--'--'-------------------------------
���--
Address(if umeren from u�on ----------- --'------''-----------
cityfTvwn ��-----'----'---- --' State-----'------- Zip Code
B. Pumping Record
1. Date ofPumping --------'------'- 2 Quantity - -----
Date � � Gonnno
3. Type of system: Cesspool(s) Septic Tank F-1 Tight Tank M Grease Trap
L] Other(describe): -------'----...-........
--'-'------------------ --
4. Effluent Tee Filter present? F� Yes R No |f yes, was Kcl*eaned? F� Yes F� No
5. Condition ofSystem:
G. System ~~~---
Name --Vehicle �
License Number
Stewart' Septic
Company ��-------- -- '— �
/. Location where contents were disposed:
StewarCs Pre-treatment Plant, 20 So. K8i|| Bradford, Na 01835 �
Signature ofHaule, oa
��--'----------- '-----''-'' - ----- -- |
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�,gnutureofRovewnopao v----- -' ----' ' ��te-------'-- ---------------
mforrn*�c-03/06 System Pumping Record-Page 1 of 1