HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 353 BOXFORD STREET 7/21/2026 Commonwealth of Massachusetts Town Of NOd AndoVer
(amity/Town of
m - stem Pumping Record Jul 202
Form 4
Health
DEP has provided this form for use by local Boards of Health. Other forms may be used, b�1f rt
tent
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. _____�
HOUSE: front a k� side rear left right )
A. Facility Information BUILDING: front back side rear left rig t
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab --- _---- ._ --
3,0
key to move your Address
cursor-do not _ MA _
use the return City/Town_ ------ — __ _ Mate Zip Code -
key,�+..`
2. System Owner:
Name
Address(if different from location)
MA
City/Town stat Zip Code
-_ — —:_._._ _ --_---.__..-__
Telephone Number
B. Pumping Record .__._�
jit
1. Date of Pumping -- - ---- 2. Quantity Pumped:
Date Gallons
3, Component: ❑ Cesspool(s) ❑ S tic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. Sy m Pumped By:
ave Tiney _ Mass 1 AA95E M ss 1 AD31 Z
Name --» � — Vehicle License Number m —
_ son Enterprises, Inc.
Company
7. LLocation wh contents ere disposeO-,
D
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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