HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1267 OSGOOD STREET 10/4/2023 Commonwealth of Massachusetts
W City/Town of No Andover 41pti3
System Pumping Record pC
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, l
use only the tab
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner: l
Name
�eaan
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat 2. Quantity Pumped. lions
3. Component: ❑ Cesspool(s) �ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes�No If yes, was it cleaned? ❑ Yes Flo
5. Observed c nditio of component pump d: ® �' V
s. syst�u�BL
Name Vehicle Li ense Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
z
in
, Date
(a
Signature of Receiving Facility(or attach facility receipt) Date
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