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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 105 SULLIVAN STREET 8/8/2024 Andover 0 Commonwealth of Massachusetts City/Town of No.Andover AUG p g 2024 System Pumping Record Form 4 ,9ern i ent 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 key to move your Address cursor-do not use the return key. City/Town State Zip Code ❑ 2. System Owner: Name tow Address(if different from location) No.Andover MA City/Town State Zip Code Telephone Number B. Pumping Record02 /0O 1. Date of Pumping Da l 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? es ❑ No 5. Observed ondition of o one umped: C© o � 6 . SystemA:V.�- r--- 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 receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1