HomeMy WebLinkAboutSeptic Pumping Slip - 108 WINDKIST FARM ROAD 12/9/2015 RECEIVED
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Commonwealth of Massachusetts JUN 10 u j,3
City/Town of NO ANDOVER
'roWN OF NORM ANDOVDR
System Pumping Record AL. DM
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 CIVIR 15,351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 108 WINDKIST FARM RD
key to move your Address
cursor-do not NO ANDOVER Ma
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
JOHNSON
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
4"D
1. Date of Pumping Date/13 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) P/Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: r
6. stem Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Si ture of'Hauler Date
ignature of Receiving Facility Date
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State Zip Code
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State Zip Code
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Telephone Number
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rl'�Ping A U t
Quantity Pumped'_. gallons
Type of System
Septic Tank Grease Trap Other (what)
Purnped
OF"n J
I 111Y F)00TER-MAlit 12 East Dracut Rd., Methuen, MA 01944
Locm.10D. V'/
'I"CTe- coiitents were disposed:0
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