HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 26 TURTLE LANE 5/21/2026 Commonwealth of Massachusetts Town of No*Andover
City/Town of
JUN 15 20,
. .....- System Pumping Record 26
Form 4
Health De&U.,t
DEP has provided this form for use by local Boards of Health. Other forms maybe
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, -ter i
use only the tab -----------
key to move your Adores
cursor-do not
—-----.........................
use the return City/Town state Zip Code
key.
2. System Owner:
—-------------- —-----
Name
Address(if different from location)
City/Town -State------ Zip---
- (�o-`3 u-— K---.............
Telephone Number
B. Pumping Record
05 64
1. Date Of Pumping Date, --.... . ..... 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 9 Septic Tank F-1 Tight Tank El Grease Trap
f-1 Other(describe): -,--------------------------- ---------------
4. Effluent Tee Filter present? E] Yes No If yes,was it cleaned? F-1 Yes n No
5. Observed condition of component pumped:
---------- -------
---U� -
6. System Pumped By:
Y)
I II-A _q�tjb
Name o Vehicle License Number
Company
7. Location where contents were disposed:
................ ---------------------........................ ------------------
.............
. ..
-- --------- ------------------- ------------ .......................
Signature"of Hauler Date
Signature of -i-v-l-n-g
Facility(or attach facility receipt) Date
-S716-n- Receiving
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