HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 46 HOLLOW TREE LANE 3/2/2026 Town of No Andover
l'-'\ Commonwealth of Massachusetts
City/Town of �br Aocto,--ev- MAR - 2 2026
System Pumping Record
Form 4
Health Department
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 1�
use only the tab lot Ln ................... ........................
key to move your Address
cursor-do not
use the return ..... A7yi-(1c>.ve-,r..................... .....................
key. City/Town State Zip Code
2. System Owner: L it
- 1 1-1----------- .............................. ....................... ...............
Name
........................... ----------------------------------------
Address(if
rent from location)
........................I--------------1—-—-—------------------------------------ .............................................. --------
State Zip Code
........... ----------___------
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: -------
Date Gallons
3. Component: F Cesspool(s) Ef-Septic Tank n Tight Tank ❑ Grease Trap
M Other(describe): --------- -------
4. Effluent Tee Filter present? E] Yes EKNo If yes,was it cleaned? [I Yes M No
5. Observed conditiQn of component pumped:
.............................
6. System Pumped By:
----------- ------------ ........................
Name Vehicle License umber
-13 C,
0mpany
7. Location where contents were disposed:
............ -----------------------------------
..........
Signature-of 919�rll Date
-------------------------- - ..---------....................... -—---------------------------.... ...........--................................ ............................
S�Fgnatur-e bf"K6ceiving Facility(or attach facility receipt) Date
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