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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 885 FOREST STREET 9/5/2023 Commonwealth of Massachusetts W City/Town of No. Andover System Pumping Record Q p5tioti3 iG M Form 4 SV 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, g�S use only the tab /1'S key to move your Address cursor-do not No. Andover MA 01845 use the return City/Town State Zip Code key. 2. System Owner: �1✓s7 n i✓l c J a�r�.e Name seem Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping te 2 3 2. Quantity Pumped: Date 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 F"'No 5. Observed c diti© of cgmponent pumped: 6. Syst Pu�Red By: Nam ��++����jj VehiclIL cense Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 S 111 Bradfor , MA r Date Same day _ Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1