HomeMy WebLinkAboutSeptic Pumping Slip - 126 Lacy St - 10/31/24 - Septic Pumping Slip - 126 LACY STREET 10/31/2024 Commonwealth of Massachusetts
ua 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: d �p
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: r
Name
Address(if different from location)
No Andover _ MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping crate Quantity Pumped: Gallons -
3. Component: ❑ Cesspool(s) �° �Sepfic Tank [,] Tight Tank ❑ Grease Trap
❑ Other(describe): - --
4. Effluent Tee Filter present? n Yes [_, No If yes, was it cleaned? � � Yes (.,, ] No
5. Observed coed' on of component pumped:
6. System Pumped By:
Nam Vehicle License Number
JL� ��
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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