HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 121 CAMPBELL ROAD 5/19/2025 Town of Not Andover
Commonwealth of Massachusetts MAR - 2 2026
City/Town of .A,�� Aidove
System Pumping Record Health Department
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
filling out forms 1. System Location:
on the computer,
use only the tab
C� .4 J4
key to move your Address
cursor-do not
use the return .........--------- .................
key. City/Town State Zip Code
2.
System
VQ Sy ste m Owner:
k or +
- C - + --------Name -- ---------------46d"s (if different from location)
-dTft /f own State Zip Code
— /
-fe-—1e p—hol Number
r=-*
B. Pumping Record 612 0 lz,5--
1. Date of Pumping Quantity Pumped:
Date Gallons
3. Component: El Cesspool(s) M"Septic Tank n Tight Tank FI Grease Trap
E] Other(describe): ...............
4. Effluent Tee Filter present? ❑ Yes n No If yes, was it cleaned? F-1 Yes R No
5. Observed condilion of component pumped:
-.t>CY
6. System Pumped By: LV�2q�'70
451m`e Vehicle License Number
WY40111 Mo..®MJT' p1q9161111_"t 11Y',
-60-mpahy
7. Location where contents were disposed:
I IS,<'<
atu 7 Hauler Date
----------- ........................ ------------- - - -------------
Signature o Receiving Facility(or attach facility receipt) Date
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