HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 54 LONG PASTURE ROAD 2/6/2024 Commonwealth of Massachusetts Town of Nc'i;Uhl Andover
= City/Town of
T�x System Pumping Record FEB 0 6 2024
Form 4
,G M
DEP has provided this form for use by local Boards of Health. Othef`;fo s ay."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,
use only the tab 6q
key to move your Address
cursor-do not MA
use the return key. City/Town State Zip Code
2. System Owne
Name —
nem
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ate 2. Quantity Pumped: alIons
3. Component: ❑ Cesspool(s) CiSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition f component pumped:
gt® All of this estimated
informAtielh is non-binding, valid only at the time of pumping. Not responsible be and the date above.
6. Syst aped B
Name Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Receiving Facility, 20 So_Mill St., Bradford, MA 01835
See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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