HomeMy WebLinkAboutSeptic Pumping Slip - 175 Stonecleave Rd - 11/27/2024 - Septic Pumping Slip - 175 STONECLEAVE ROAD 11/27/2024 Commonwealth �� &H ��
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System Pumping Record
Form 4
DEP has provided this fnnn for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same authat provided here. Before using this form, check with your
|000| Board of Health tn 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 31O CKAR 15.351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key m move your xoomss
cursor do not
use the return
key. City/Town_ System Owner:
Name T
Address(if different from location)
No Andover M8
City[Town State Zip Code
� Telephone Number
B. Pump^ng Record
1. Date ofPumping 2.—4'. �LQuantity
Date
3. Component: E] Cesspool(s) SepticTank El Tight Tank [ | Grease Trap
[] Other(describe):
4 EfDuen�T�eFi|t�rpr�eont? �l Ye� �� m" If w�oito|e�nad? �� Yes �l No
� �� ��-~" . �� ��
5. Observed condition of cor ponentpumped:
_ �System('PPame Vehicle License Numberp�d IC
58So Kimball St B/adfnrdMA
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.upc-11/12 System Pumping Record~Page Iof1
