HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 OXBOW CIRCLE 5/6/2024 p e„rah Anever
C_ Commonwealth of Massachusetts
City/Town of No Andover MAY 0 6 2024
System Pumping Record
Form 4 ''' p0tment
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, �U ��tw c2c `r—C /9-
use only the tab
key to move your Add ss (
cursor-do not d�j�, �n�p ye
key. 2 S�C-L
use the return vCity/Town State Zip Code
2. System Owner:
t� ,1� S �
0
Name
ratan
Address(if different from location)
No Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da 2. Quantity Pumped: Gallons `�
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes-U No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pump d:
6. Syst mped By:
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility n:ceipt) Date
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