HomeMy WebLinkAboutSeptic Pumping Slip - 151 SANDRA LANE 7/30/2018 Commonwealth of Massachusetts RECEIVED
City/Town of 1U1,, 3020V3
System Pumping Recor� �i PAR11AEP41"ANDOVER
Form 4 � l���w� i��..�a i��:ce it-��
DEP has provided this farm 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, 11)
use only the tab , �� ��r" � L"11, x
key to move your address
cursor- net � i 'f 1/�
use the return CI ITawn `�
key. tY State Zip Code
2. System Owner:
Name
Address(if different from location)
Clty/Town State Zip Cade
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- _-
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
i
5. Observed condition of component pumped:
6. System Pumped By:
l C'S I Q l �
Name Vehicle License Number
PCompany —�-
7. Location whe/n contents were disposed:
S_ ! PfH signature aul �-- -
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11112 System Pumping Record•Page 1 of 1
