HomeMy WebLinkAboutTrailer Septic - Septic Pumping Slip - 21 CLARK STREET 2/6/2024 ILN Commonwealth of Massachusetts To'm oi Andover
W City/Town of No. Andover
a
System Pumping Record FEB 0 6 2024
Form 4
DEP has provided this form for use by local Boards of Health. Other.forms may be used, bUtthe
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,
use only the tab /v Gtj►�l r C � r�9
key to move your Address a
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
r� 2. System Owner:
Same h
Name
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping DMZ 2-4 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ✓ r-11l'1.1 r s e— el ) RC
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6d 0 7' All of this estimated
information is non-binding valid only at the time of pumping Not responsible beyond the date above.
6. System Pumped By:
firs (-r7 j- ► ��L9? r�
Name Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Receiving Facility, 20 So. Mill St., Bradford MA 01835
U) See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record•Page 1 of 1
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