HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 78 TANGLEWOOD LANE 12/2/2024 LN Commonwealth of Massachusetts
x City/Town of No Andover
System Pumping Record
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 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 N
filling out forms 1. System Location:
on the computer,
use only the tab g ° � F ' "�
key to move your Address
cursor-do not _� /a P f �� 13 /1 Z e^�v �� r �! " �y-,
use the return - - ... ......__.._------ _.._____...._.._____ --- ___._ .......-..........____�.
key City/Town State Zi P
2. System Owner:
rah
Name
__ _�
Address(if different from location)
No Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping o�i 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) Lq Se tic'Tank Tight Tank Grease Trap
Other(describe): —
4. Effluent Tee Filter present? [.. � Yes �__ No If yes, was it cleaned? El Yes E] No
5. Observed condition of component pumped:
6. SysteZPpedd B
Name Vehicle Licensber ---
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Hauler _.__ Date
Signature of Receiving Facility(or attach facility receipt) Date
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