HomeMy WebLinkAboutSeptic Pumping Slip - 10/24/2024 - Septic Pumping Slip - 474 WAVERLY ROAD 10/24/2024 p Commonwealth of Massachusetts TOWN Noah Andover
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w = System Pumping Record FEB _ 4 025
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Form 4
DEP has provided this farm for use by local Boards of Health. (WWWsQ,#j;@b1W"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:
on the computer, ° C use only the tab ---- _ __° �. W ..
key to move your Address - ......... ..... . .._ c� ___.__
cursor-do not ,;
use the return . .. _.... .
key. City/Town State Zip Code
y 2. stem Owner:
r
name _. ... ..
Address(if different from location)
City/Town State Zip Code
Telephone Numbe 11 r.
B. Pumping Record
, .
1. Date of Pumping 2. Quantity Pumped:
Ga 11 te Gallons
3. Component: Q Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes,,n No If yes, was it cleaned? FQ Yes No
M�
5. Observed condition of component pumped:
6. System Pumped By:
. °.l. ._ _......_._... __ _.._ -------- __.._._
e Vehicle License Number
„
Compan
7. Location wh o ents were disposed:
„rat
m. -
Signature Hauler Date
Si
gnat re of oei yang Facility(or at facility receipt) Date
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