HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 36 PATTON LANE 1/19/2022 RECEIVE►
BAN
Commonwealth of Ma ssachusetts 192022
City/Town of /U 1s w RTH ANDOVEF4
TOWN OF NO
System Pumping Record HEALTH DEPARTMENT
iv^M
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, ,n*4o A\ L�N
use only the tab T, !�
key to move your Address r
cursor-danot N`-)`l- AN�����\ O
use the return City/Town State Zip Code
key.
2. 7(3
Owner:
,�
�I Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
Q
1. Date of Pumping Date
I 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) `Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes VNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
he�v� �� sal ids
6. SyateMPumped By:
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill t. ford,MA /
i t of Kauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1