HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 20 WINTERGREEN DRIVE 11/13/2024 Commonwealth �� Massachusetts
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No Andover
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 as that provided here. Before using this fnrm, check with your
local Board of Health to determine the form they use. The System Pumping Record must bo submitted tu
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CK8R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key m move your puoreox
cursor'uonot -
use the nmum
key. City/Town State Z-
Code
2. System Owner
Name
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Oota of Pumping bate2� Quantity Pumped:
Gallons
��.
3. Component El Cesspool(s) ~��/ueptinTonk Fl Tight Tank E Grease Trap
[:] Other(describe):
4. Effluent Tee Filter pnaamnt? E] Yes 5�No }f yes, was itcleaned? Yen No
5. Observed condition of component pumped:
G. 8 Pump dB
rTia me Vehicle License Number
SD wart'oSeptic 58 So Kimball St. BnadfordK8A
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
77
Signature of Hauler -bate
Signature of Receiving Facility(or attach facility receipt) Date
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