HomeMy WebLinkAboutSeptic Pumping Slip - 11/6/24 - Septic Pumping Slip - 17 SUGARCANE LANE 11/6/2024 Commonwealth �� K8 �
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System Pumping
Record
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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 anthat provided here. Before using this form, check with your
|noa| Board of Health to determine the form they use. The System Pumping Record must besubmitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCK4R15.351.
A, Facility Information
Important:When
filling out forms 1. System Location: /~
on the computer,
use only the tab
key m move your *«oreao /y
cursor do not �
use the return
key. City/Town State Zip Code
_
2. System Owner:
Name
Address(if different from location)
No Andover MA
City/Town State Zip Code
Telephone Number
B~ Pump`ng Record
1. Date ofPumping =���� = 2.
Ouanthypumped:Date
3. Component: [l Cesspool(s) Septic Tank Fl Tight Tank Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? [ YesT��No |f yes, was i(cleaned? Yes No
5. Observed condition of componentpumped:
6.
System Name Vehicle License Number
-
So KimballSt Bradford,MA
Company
7. Location where contents were disposed: