HomeMy WebLinkAboutSeptic Pumping Slip - 2024-07-18 - Septic Pumping Slip - 21 SOUTH CROSS ROAD 7/18/2024 Commonwealth of Massachusetts Town of orb Andover
City/Town of FEB
._ 4 2025
System Pumping Record
Form 4 (�'`$c@{$
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DEP has provided this form for use by local Boards of Health. Other forms may be used, 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, _
use only the tab
key to move your Address
cursor-do not
use the return - - --- - - -_._._..- - - ---- — ............ -
key.
ty State Zip Code
bQ 2. System Owner:
Name
6M ----- -
--
Address(if different from location)
........... .... .._.._........ _..._.__... ---- -
City/Town State Zip Code
Telephone umber
B. Pumping Record
1. Date of Pumping Dat _ 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- ---- - ------ -.__ - --- ...-
4. Effluent Tee Filter present? XYes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed co dltion of component pumped:
6. System Pumped By:
Name r Vehicle License Number
Company
7. Location wher contents were disposed:
Signa ur of aide. Date
_ -----_-_. ------ __ _ .... -
5ignature o eceiving Facili or attach facility receipt) Date
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