HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 332 CAMPBELL ROAD 6/2/2026 <n� Town Of 4ndov
N- Commonwealth of Massachusetts
City/Town of ., (Vovtr JUN
System Pumping Record 2026
Form 4 110'71tll L)E?PaLtrne,7t c
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, act
use only the tab
key to move your Address
cursor-do not o k�-k
use the return
key. City/Town Zip Code
2. System Owner:
..........Rukel-
Name
Address(if different from location)
................... .......................................... -------
City/Town State 7 Zip Code
-
Telephone Number
B. Pumping Record
1. Date of Pumping ....................------------------
2 Quantity Pumped:.
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
R Other(describe):
4. Effluent Tee Filter present? R Yes No If yes,was it cleaned? F1 Yes R No
5. Observed condition of component pumped:
6. System Pumped By:
..
-7&
.............. ----------....... ---------------------- ---------------------------
N e Vehicle License Number
fair
Company
7. Location where contents were disposed:
................ ---------U-
....... Signature,. "Hauler Date
...........----------- ------
Signature of Receiving Facility(or attach facility receipt) Date
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