HomeMy WebLinkAboutSeptic Pumping Slip - 31 Oxbow 9.25.2024 - Septic Pumping Slip - 31 OXBOW CIRCLE 9/25/2024 Commonwealth of Massachusetts
x r City/Town of No Andover
m System Pumping Record
w
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
ruing out forms 1. System Location:
on the computer, /
use only the tab
key to move your Address
cursor-do not
usethe return ___.__ __...........___..._-_._ __......___...----...__._ __._....... _ __._._........._____..._.__— -.._._..._..._ _._..---.-_._---
key City/Town State Zip Code
2. System Owner:
Q ._....
c.w.
Name �
retr�n ----
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping ..._..�...�...� .�.�..�_. -
Record
Date �� . Y pGallons f
1. Date of Pumping2. Quantity Pumped:
3. Component: Ej Cesspool(s) Septic Tank (- Tight Tank [.] Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? [_] Yes [ -_ o If yes, was it cleaned? E_] Yes No
5. Observed condition of cCm
ponent pumped:
' - '
6. Syste P roped y: 14
_ ..,.c .
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
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