HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1439 GREAT POND ROAD 4/22/2024 Commonwealth of Massachusetts
W City/Town of AndaG
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W° System Pumping Record APR 2 2 ZK4
Form 4
GSM
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,
use only the tab 1�---1?�-`'1 -Porld
key to move your Address � _
cursor-do not NprTU,1
use the return City/Town State Zip Code
key.
2. System Owner:
-jay-e- o-4+t
Name
aes
Address(if different from location)
Cityrrown State Zip Code
q-1•3-- 7jS-- 3/33
Telephone Number
B. Pumping Record
2
Ste'%
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [�No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
-?c>CA
6. System Pumped By:
Name ' Vehicle License Number
IA*o t A•
Company
7. Location where contents were disposed:
H
Sign re auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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