HomeMy WebLinkAboutSeptic Pumping Slip - 35 Woodbery Ln - 10-21-2024 - Septic Pumping Slip - 35 WOODBERRY LANE 10/21/2024 is
Commonwealth of Massachusetts
0 City/Town of'No Andover
System Pun) in Record
f Y p
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 Healthy 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
flung 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:
tad
Name
Address(if different from location)No Andover ^� MA
City/Town State Zip Code
Telephone Number -- ---
B. Pumping Record
1. Date of Pumping to 2. Quantity Pumped: Gall ns
_._._.
3. Component: (.]] Cesspool(s) JY'Septic Tank [........� Tight Tank [_] Grease Trap
Other(describe): - —
4. Effluent Tee Filter resent?
p �_-_ Yes -__ No If yes, was it cleaned? [ ] Yes ❑ No
5. Observed condition of component pumped:
6. Syste um ed 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
Signature of Hauler Date -
Signature of Receiving Facility(or attach facility receipt) Date
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