HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 66 SPRING HILL ROAD 5/29/2025 NVVV#1 U1 IvOrth Andover
�L\ Commonwealth of Massachusetts MAR - 2 2026
City/Town of
@ Het
System Pumping Record 0�&�Partrnent
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 CM R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not k?ck ve'—
use the return ... ...........................................
key. City/Town State Zip Code
2. System Owner:
30,-,-,c---).L4-r- ...... ---------- —------
Name
Address(if different from location)
City/Town State Zip Code
U2 -S
Telephone Number
B. Pumping Record
/
1. Date of Pumping Date Quantity Pumped: Gallons
3. Component: F] Cesspool(s) Septic Tank ❑ Tight Tank 0 Grease Trap
❑ Other(describe): .......
4. Effluent Tee Filter present? n Yes No If yes, was it cleaned? ❑ Yes F-1 No
5. Observed condition of component pumped:
6. System Pumped By: (A)(Oq 17 0
7' A-
Name Vehicle License Number
AP . ........-
Company
7. Location where contents were disposed:
----------- ------------
� .......
sioat r 6 of ler Date
gh
-------........................
Signature of Receiving Facility(or attach facility receipt) Date
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