HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 115 OGUNQUIT ROAD 11/11/2025 IE-\ Commonwealth of Massachusetts lbwn of NoMh Andover
z City/Townof _)Vor4-k vtw-
MAR - 2 2026
System Pumping Record
_:❑ Form 4
Health
DEP has provided this form for use by local Boards of Health. Other forms may be usep, beupt�jtment
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-4
useonly the tab ............ ....... .......... —------ -----------...................................
key to move your Address
cursor-do not g C>1 81-1
use the return -------------- ----------
key. City/Town State Zip Code
Z System Owner:
are -------------------- ............................ ------------ -----------
Address(if different from location)
--------------------- -City/Town State Zip Code
..........
Telephone Number
B. Pumping Record
1. Date of Pumping --Date-.- 2. Quantity Pumped: G-allons ....................
3. Component: El Cesspool(s) ER"'Septic Tank F-1 Tight Tank R Grease Trap
❑ Other(describe): ..........-...........
4. Effluent Tee Filter present? E] Yes 2/No If yes, was it cleaned? [] Yes ❑ No
5. Observed condition of component pumped:
--(� co C� - ---
6. System Pumped By:
q_j
Vehicle License Number,
_ '_.. -_
tia
..............
Company
7. Location where contents were disposed:
1 12� .......................... --------------
.......... ----------- ..................—
Signatu of Haul Date
...............
Signature of Receiving Facility(or attach facility receipt) Date
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