HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 121 OLD CART WAY 4/16/2026 Town of Nod Andover
L\ Cornmonwea Massachusetts
City/Town of pc-! x Ancicniex- JUN 15 2026
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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, k
use only the tab �ta-� 4 ................... ........--------- ...............
key to move your Address
cursor-do not
use the return ------------ ------------ ...............----..................................
key. City/Town State Zip Code
2. System Owner:
VQ
................--------- .......... -------
Name
...............
Address(if different from location)
CitylTown Stat Zip Code
47 -As� X I -----------
Telephone Number
B. Pumping Record
1. Date of Pumping -Da-t.e ........... 2. Quantity Pumped: G-a,Ions l -------------
3. Component: n Cesspool(s) Septic Tank ❑ Tight Tank R Grease Trap
M Other(describe): 1-1-1-1-1----------------------- ---------- ------------------------
4. Effluent Tee Filter present? Ej Yes Eo'/No If yes, was it cleaned? n Yes M No
5. Observed condition of component pumped:
............
-------
6. System Pumped By:
G, W�Q q
........... ........................................ ................................
me Vehicle License Number
-- b V- A..�f.>. L I-
Company
7. Location where contents were disposed:
LIIS .._.
................
1 (02 1 &?
------------ .....................
rid le Date
Si �"iving Facility(or attach facility receipt) Date
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