HomeMy WebLinkAboutSeptic Pumping Slip - 224 Raleigh Tavern Lane - 9.12.2024 - Septic Pumping Slip - 224 RALEIGH TAVERN LANE 9/12/2024 Commonwealth of Massachusetts
- - City/Town of No Andover
System Pumping Record
Form 4
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
tilling out forms 1. System Location:
on the computer, .. l-
use only the tab
key to move your Address
cursor-do not
use the return
key. City/lawn State Zip Cade
VQ 2. System Owner: 14 h hi
Name
Address(if different from location)
No.Andover MA
City/Town - state Zip Code -
Telephone Number
B. Pumping Record
1. Date of Pumping Dat 2. Quantity Pumped: Gallon
3. Component: Cesspool(s) )Septic Tank [_� Tight Tank [] Grease Trap
[[ Other(describe): — - — -- --- -- --
4. Effluent Tee Filter present? ❑ YesX No If yes, was it cleaned? [] Yes [. No
5. Observed condition of component pumped:
6. S umped 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
rV
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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