HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 111 BROOKVIEW DRIVE 5/8/2025 Commonwealth of Massachusetts Town of NOM Andover
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C ity/Town of ZZr" '4'-rf o
MAY 15 2025
System Pumping Record
Form 4
Health D%
DEP has provided this form for use by local Boards of Health. Other forms may be u e' qWfin t
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 CM R 15.351
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, ic
use only the tab f> Dr
.............
key to move your Addr ssu &
cursor-do not
use the return Zip Code
key. City/Town State
2. System Owner
t
C41
Name
..........
Address(if different from location)
Cit
State, Zip Code
-telephone Number
B. Pumping Record
1. Date of Pumping Date.1-I -.............................. 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) J2-Septic Tank R Tight Tank Fj Grease Trap
F1 Other(describe): --------------- .----............ ............------- . ......
4. Effluent Tee Filter present? ❑ Yes F-1 No If yes, was it cleaned? M Yes Fj No
5. Observed condi-on of component pumped:
--------------- ------ ----------- ------
6. System Pumped By: -G11(o 7 47 0
❑___11�0��----k--........... ---------------- ............................................ ---------------
Name Vehicle License Number
Company
7. Location where contents were disposed:
--------------------------- --------------------- -—------------ -----------------------------------
Sign'atur o Hauler Date
......... ........... -------------- --------------------------- .................. ----------------------------............ --------------
Signa ure of ceiving F ity(or attach facility receipt) Date
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