HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1551 OSGOOD STREET 2/6/2024 Commonwealth of Massachusetts 6
W City/Town of No. Andover
a System Pumping Record FEB 0 6 2024
Form 4
M
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, 7 5
use only the tab
key to move your Address
cursor-do not No. Andover
use the return __ _ MA 01845
key. City/Town State Zip Code
2. System Owner:
r� Same �
— - C n ir✓a V r
Name �j 1Rf��t�oi�c iZ-Q
gun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
�j
1. Date of Pumping 000
p 9 TDe 2. Quantity Pumped:
Gall ns
3. Component: ❑ Cesspool(s) L/ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component plumped:
✓'e!j V1 ny,+ 5 f�S All of this estimated
Information Is non-binding, val only at thetime of pumping Not responsible beyond the date above
6. System P mped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Receiving Facility, 20 So. Mill St., Bradford, MA 01835
See above
ignature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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