HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 25 GILMAN LANE 11/11/2025 Commonwealth of Massachusetts Town of Andover
City/Town of Mcf-jh A+*Nd-0ve_,,(-
MAR - 2 2026
System Pumping Record
Form 4
Health Deartment
DEP has provided this form for use by local Boards of Health. Other forms may be u , bu he
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 CIVIR 15,351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, r7i use only the tab ---------------------------
key to move your Address
cursor-do not
use the return -AIJ ................
key. City/Town State Zip Code
2. System Owner:
('�,- ----------------------------------------------
Name
-------------
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 11
2-5
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: E] Cesspool(s) [O"'Septic Tank D Tight Tank F-1 Grease Trap
R Other(describe): --------- ........------
4. Effluent Tee Filter present? R Yes �r No If yes,was it cleaned? R Yes F-1 No
5. Observed condition of component pumped:
6. System Pumped By:
(-d,
—--------- ------- -Z
Name Vqh1cle License Number
x, /A
C c
ompany
7. Location where contents were disposed:
......................
Signature 0 auuler Date
Signature of Receiving Facility(or attach facility receipt) Date
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