HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 BRIDGES LANE 4/9/2026 Commonwealth of Massachusetts Town of NCI h Andover
City/Town of
MAY 13 2026
System Pumping Record
Form 4,
Health,
t
DEP has provided this form for use by local Boards of Health. Other forms may be Used,'Ma
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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ---................ S
key to move your Address 7-
cursor-do not
use the return _v- ........
key. City/Town State Zip Code
VQ_ 2. System Owner:
name ..............-
-----
Address(if different from location)
-C4 lt�/To ----------- ......
n State Zip Code
If eie-p-h-o-n-e--N---um-ber,
B. Pumping Record
1, Date of Pumping Date 2. Quantity Pumped: Gallons 0-
3. Component: Cesspool(s) Septic Tank n Tight Tank El Grease Trap
Other(describe): ----------------------
4. Effluent Tee Filter present? ❑ Y�s�FA jNo If yes, was it cleaned? F] Yes n No
5. Observed condition of component pumped:
6. System Pumped By:
............... ------
Name Vehicle License Number
_
................... _'P
Company
7. Location whTre I contents were disposed:
Signature of Hauler Date
-§"i-g-n-a-ture-—ofRecei-v-in g F,a--c-il-it--y",(-o--r-"a-,ft—a,c,li--f-a--c-iti-ty-rec'eip-t-) -bat'e- ----—------------------------------
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