HomeMy WebLinkAboutSeptic Pumping Slip - 11/11/24 - Septic Pumping Slip - 124 TUCKER FARM ROAD 11/11/2024 Commonwealth �� K� �
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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 oe 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 31OCK8R15�351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key m move your Address
cursor do not
use the return
key. City/Town State Z-
Code
_ System Owner:
Name
Address(if different from location)
No Andover NA
City/Town State Zip Code
Telephone Number
B. Pumping Record — _-
1. Date ofPumping 2� Quantity
3. Component: Fl Cesspool(s) SepticTenk E] Tight Tank E] Grease Trap
E] Other(describe):
4. Effluent Tee Filter present? E] Y o |f yes, was itcleaned? Yes [l No
6. Observed condition of component pumped:
B. System Pumped B
Nam r e Vehicle License Number
Stewort'o Septic 58So Kimball St. BnadfordK0A
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach Date
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