HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 BEECHWOOD DRIVE 10/6/2021 Commonwealth of Massachusetts
RTH
City/Town of TOHEALTH D PARTMENT ANDOVER
System Pumping Record
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
filling out forms 1. System Location:
on the computer, gee-
n
use only the tab .y
�1,� eCCA I'yo�/�Jr
key to move your Address /
cursor-do not //6r Ll r'j d 4✓L � rn
use the return City/Town State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
97�-SS7- .�SS3
Telephone Number
B. Pumping Record
_ G G-
1. Date of Pumping 1 2. Quantity Pumped: 1, coo
Date Gallons
3. Component: ❑ Cesspool(s) /ff Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present?9 Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
600 d
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of H uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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