HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1627 OSGOOD STREET 8/8/2024 i r,�;h Andover
� Commonwealth of Massachusetts J°.ar u ` °w`
w . City/Town of
w° System Pumping Record AUG o g 2024
Form 4
oM - a!-lMni t
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, J 0� OD J
use only the tab IIIJJJ��� ,
key to move your Address ��r
cursor-do not !V p rf t &JOLt err MA
use the return CityCity f wo nwo n State Zip Code
key.
2. System Owner:
rab
Same
Name
rerun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �'1= 2. Quantity Pumped: Q �
Date Gallons
3. Component: ❑ Cesspool(s) 2/septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Ivyes ❑ No
5. Observed condition of component pumped:
CCU All of this estimated
information is non-binding, valid onlyht the time of pumping. Not responsible beyond the date above.
6. System
Pumped By:
I` Q
Name Vehicle License Number
m n Co pa y
7. Location where contents were disposed:
Stewart's Receivin Facilit So. Mill St., Bradford, MA 01835
~ See above
i at o ler Date
Signature of Receiving Facility(or attach facility receipt) Date
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