HomeMy WebLinkAboutSeptic Pumping Slip - 201 Carlton - 10-17-24 - Septic Pumping Slip - 201 CARLTON LANE 10/17/2024 Commonwealth �� Massachusetts
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No Andover
System Pumping Record
Form 4
DEP has provided this form for use by |ooe| Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided hens. Before using this fnrm, check with your
local Board nf 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 310CY0R1G.351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key m move your Address
uunm, do not
use the return Code
key. City/Town State Zip
_ System Owner:
VC] ")z
Address(if different from location)
No Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date ofPumping * 2. Qrll"—
Date — uantityGallons
3. Component: F] Cesspool(s) 4- Septic Tank El Tight Tank U Grease Trap
E Other(describe):
4. Effluent Tee Filter present? [] Yes No |f yes, was kcleaned? LJ Yes LJ No
5. Observed condition of component pumped:
G. System Pumped By:
Name Vehicle License Number
S ' Septic 8 So Kimball St Bradford,MA
Company
7. Location where contents were disposed:
20Sn K8i|| St Brodford [WA
Signature of Hauler Date
§-gnature of Receiving Facility(or attach facility receipt) 5a1a-
t5fonn*.umc-11/12 System Pumping Record^Page, o,1
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