HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 283 CAMPBELL ROAD 6/4/2025 Commonwealth of Massachusetts �� �
x City/Town of No.Andover JUAI 4 202,E
System Pumping Record
4
Form 4ePart
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
filling out forms 1. System Location:
on the computer, r ��
use only the tab
key to move your Address
cursor-do not
use the return --------
key.
City/Town State Zip Code
2. System Owner.
rib
Name
Addre --(if---.di..-..fterent... ._f. ...._ -----... .,...w..._...__... --- ................. ..._._. —. .-----
...----
.. .........
ssrom location)
No.Andove_r MA
City/Town State Zip Code
Telephone Number
B. Pumping Record _
1. Date of Pumping fate --- -- 2. Quantity Pumped: Gallons
3. Component: ] Cesspool(s) �"Septic Tank ] Tight Tank Grease Trap
Other(describe): _-_- --_ ..._..._.....
resent' � � Yes � �
4. Effluent Tee Filter p If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
-----.... ---
6. Syste umped B
_.................. ...�- .-..__.._.......__::. -----� _....._......- -- -- --- � -._.. _..------ -.._..........---
Name Vehicle-License Number
Ste a s Septic 58 So Kimball St Bradford,MA
Com ny
S-_ - _.._
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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