HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 279 BOXFORD STREET 11/26/2025 Commonwealth of Massachusetts AndOver
City/Town of Aocto volo' MAR -2 2026
System Pumping Record
Form 4 'Partment
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, / � - I 'L ]- -
use only the tab - __ J___ _
--------------
key to move your A dress
cursor-do not 441
use the return -.1...............
key. City/Town State Zip Code
2. System Owner:
--------
Name
Address(if different from location)
tiffow n----------------------------- 's-t-a"
te Zip Cade
-Telephone Number
B. Pumping Record
1. Date of Pumping --Date.. --................................. 2. Quantity Pumped: Gallons
3. Component: E] Cesspool(s) [Septic Tank R Tight Tank ❑ Grease Trap
F-1 Other(describe): ----------------------------- --------------—........................
4. Effluent Tee Filter present? F] Yes Eg/No If yes, was it cleaned? ❑ Yes n No
5. Observed condition of component pumped:
6. System Pumped By:
................
_Z11-1--a-1.......... ---------------------------
Name------------- Vehicle Licenpe Number
Company
7. Location where contents were disposed:
5 --c
---------- ----------- ----Si ature Mauler❑ Date
-------------
Signature ceiving Facility(or attach facility receipt) Date
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