HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1935 SALEM STREET 6/4/2024 Commonwealth of Massachusetts bpndo0
City/Town of No. Andover �o�a
System Pumping Record SUN p 4 2024
Form 4 et
�
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, n
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
LaCha Nie
Name -
�un
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping /6- 2. Quantity Pumped: (I oG
Date 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:
(_'r�U rc� i P ve 1 Up �-o CDUe v' All of this estimated
information is non-binding, valid only at the time ofpumping. Not responsible beyond the date above.
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Receiving Facility, 20 So. Mill St_, Bradford, MA 01835
IA a go h �-oyl es See above
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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