HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 134 CANDLESTICK ROAD 4/28/2026 Own Of lVorth Commonwealth of Massac usetts Andover
City/Town of -ALLO-\ JUN 16
026
System Pumping Record
Form 4 Hec-11th I)ep
DEP has provided this form for use by local Boards of Health. Other forms may be usep,
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 1-5q-
key to move your Address
cursor-do not
use the return 00
------------ ..........
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Ity/To ........................0;�w State Zip Code
Telephone Number
B. Pumping Record
04 1
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: Fj Cesspool(s) Co/septic Tank n Tight Tank M Grease Trap
❑ Other(describe): ----------------
4. Effluent Tee Filter present? F-1 Yes Na If yes, was it cleaned? F-1 Yes [] No
5. Observed condition of component pumped:
6. System Pumped By:
zJ ------------ ............------------------------------------------------------
ame Vehicle License Number
0*0
Company
7. Location where contents were disposed:
0
----------------
Signature of Hauler Date
Signature of-of--R--e--c-e-i-v--ing—Facili--ty--(-o--r attach facility- receipt)-- —Date
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