HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 21 CLARK STREET 10/12/2023 Commonwealth of Massachusetts
City/Town of No. 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, �J
use only the tab '21 L
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
r�
2. System Owner:
Same
Name - - - --
�sn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date - 12 Z3 2. Quantity Pumped: Gallons -
3. Component: ❑ Cesspool(s) 17Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes 1�No
5. Observed condition of component pumped:
All of this estimated
information is non-binding, valid only at the time of pumping. Not responsible beyond the date above.
6. Syste urn
U�jr
Nam Vehicle Li6ense Number
Company
7. Location where contents were disposed:
Ste !lit , 20 So. Mill St., Bradford, MA
i"_�4t�_ I _ See aboveSee above /! �3�3
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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