HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 53 GLENNCREST DRIVE 9/17/2025 10wrl al' Nciih Andover
Commonwealth of Massachusetts MAR 2 2026
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City/Town ofILL
System Pumping Record Heaftl i Department
M, 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 CIVIR 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 7
usethe return ............................ --------------------- . ..................
key. Cityrrown State Zip Code
2. System Owner:
rl
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Name
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Address(if different from location)
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CityfTown State _7 (7 q Zip Code
J15-3
Telephone Number
B. Pumping Record 1-7 —
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: F1 Cesspool(s) [LSeptic Tank Fj Tight Tank R Grease Trap
F-1 Other(describe): ------------------ ...........................---------
4. Effluent Tee Filter present? E] Yes [ No If yes,was it cleaned? ❑ Yes F-1 No
5. Observed condition of component pumped:
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6. System Pumped By:
\Aj Q0 --I
&�t &(-d C1 I �J
.......... ------- ..........---..........
Name Vehicle License Number
ty)
Company
7. Location where contents were disposed:
........... .......... --------------
Si n�rt
re off H I er Date
Signature of Receiving Facility(or attach facility receipt) Date
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