HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 210 FARNUM STREET 6/2/2026 Commonwealth of Massachusetts Town of Noqj�AndOver
City/Town of Albr ik Anc6xr
JUN 15 20
System Pumping Record
Form 4 Health De
DEP has provided this form for use by local Boards of Health. Other forms may be us P 9AWnt
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, — , , 4 .3
use only the tab Ir. ....... --------- ........................
.. z
key to move your Address
cursor-do not
use the return ------
key. ity/Town
State Zip Code
2. System Owner:
er
_(------------------
Name
.............. -—---------------------------------------- --——---------------------------------
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
0(o 7 ke
1. Date of Pumping 2. Quantity Pumped:
Date jo Gallons
3. Component: F-1 Cesspool(s) F-1 Septic Tank R Tight Tank M Grease Trap
M Other(describe):
4. Effluent Tee Filter present? n Yes EyNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed Condition of component pumped:
ko 6. System Pumped By:
.................___ -__!L�
N Vehicle License Number
Company
7. Location where contents were disposed:
Is
', Hauler
,qqgtum�,t Hauler Date
Signature of y(or attach facility receipt) Date
R—e-c-e-iv-i-n---g'---F-a-ci—lit
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