HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 217 GRAY STREET 5/7/2026 I (L�r-1 ) Town of Nmh Andover
Commonwealth oJ Massachusetts
City/Town off JUN 15 2026
wM 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, C
use only the tab
key to move your Address
cursor-do not
usethe return ---------------------------- -------.........................
key. City/Town State Zip Code
4:1 2. System Owner:
..............-
Name
Address different from location)
State Zip Cade
a
---- -----------
12 ---------
T 'P
Telephone Number
B. Pumping Record
1. Date of Pumping Date....................... 22............... Quantity Pumped: Gallons
1 Component: F-1 Cesspool(s) 19/septic Tank Fj Tight Tank F-1 Grease Trap
❑ Other(describe): ..........................................................
4. Effluent Tee Filter present? V/Yes RFvNo If yes, was it cleaned.? 2/Yes, M No
5. Obs d condition of component pumped: +r""aced
--Mxxl............... -------------------------------------- --------------------------------- —---------
6. System Pumped By: c
1710
--------------
Name Vehicle License Number
V
Company
7. Location wher ntents were disposed:
...........------------ ------ -------- ---------
------------------------------- --------------c>511 11- ................ ..................
S' ature of auler Date
-------------- -----------
Sign a rty(or attach facility receipt) Date
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