HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 71 CANDLESTICK ROAD 10/27/2025 Commonwealth of Massachusetts
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System Pumping Record
Form 4
DEP has provided this h)nn 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
|Dma| Board of Health to determine the form they use. The System Pumping Record must be submitted to
the |Ooa| Board of Health Or other approving authority within 14 days from the pumping date in
accordance with 31OCK4R 15.351
A. Facility Information
Important:When
filling out forms 1. System Location,
on the computer,
use only the tab
key vo move your Address
ousu,-uomot
use the return
key. City/Town ���� ��e Zip Code
________
Z System Owner:
Nome �-
SAME �
No.Andover MA
C State -�—'---------- Zip
B. Pu00p~ng Record ' - -
1. Date ofPumping - Gallons
Quantity Pumped:
3. Component: L] Cesspool(s) ptic vs4Z
Tank Tight Tank � G��Trap
[l Other(describe):
4. Effluent Tee Filter present? U Yes No If yes, was it cleaned? U Yes ��
5. jObserved condi
S. System Pumped By:
Name Vehicle License Number
Stewart' Septic 58So Kimball St. Bradford,MA
7. Location where contents were diopoa*d�
20 80.K8i|| St. Bnadford K8A
8ignotumofReueiwngraoi/hy(orenachfaoi|ityreceipV Date--