HomeMy WebLinkAboutSeptic Pumping Slip - 1267 Osgood St - Septic Pumping Slip - 1267 OSGOOD STREET 10/4/2024 Commonwealth of Massachusetts
a City/Town of No.Andover
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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
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:
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Address(if different from location)
No.Andover _M_A
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping date � 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) � Se tic Tank I--] Tight Tank ❑ Grease Trap
Other(describe): --
4. Effluent Tee Filter present? [v] Yes [_] No If yes, was it cleaned? IdYes [] No
5. Observed condition of component pumped:
6. System Pumped 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
62
Signature of Haul er Date
Signature of Receiving Facility(or attach facility receipt) Date
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