HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 47 BOXFORD STREET 11/5/2025 Commonwealth of MassachusettsTu Town of Wit Andover
City/Town of - 2 2026
MAR
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( (5 0)(
use only the tab ........... .................-
key to move your Address
cursor-do not &(,A
use the return ---—----------------- ....................
key. City/Town State Zip Code
VQ 2. System Owner:
Name
............- ------
Address(if different from location)
................
City/Town State Zip Code
-1(4.0R
Telephone Number-
B. Pumping Record
91
1. Date of Pumping Da I 1 Date 2. Quantity Pumped: Gallons
3. Component: El Cesspool(s) &6eptic Tank F-1 Tight Tank n Grease Trap
❑ Other(describe): ---------------- -------------
4. Effluent Tee Filter present? ❑ Yes [g/No If yes,was it cleaned? ❑ Yes R No
5. Observed condition of component pumped:
--------------------------------
6. System Pumped By:
Y'N r
Name ---------------------------- Vehicle License Number .................
Ai ,
ompany I- J,
.. .........
7. Location where contents were disposed:
......—------- -------- ❑ ---------- -----------------
Si 6ture Hauler❑ Date
Signature-tof =,dying--- -Facility-- -(-o-r attach facility rece-i p t-)---- ba-te----
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