HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 73 FOREST STREET 6/18/2026 Commonwealth of Massachusetts Town of Nod AndoVer
City/Town of
System Pumping Record JUL -6 2o26
Form 4
eajtp ap.,
DEP has provided this form for use by local Boards of Health. OtherH form ad
information must be substantially the same as that provided here. Before using this form, c�helcwith 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 16.351. ------
6 HOUSE: KIr"ont)back side rea left' right
A. Facility Information BUILDING: '*'� back side rear right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, --7
use only the tab
key to move your Address
cursor-do not MA
use the return CitylTown State Zip Code
key.
2. System Owner:
(*
Name
Address(if different from location)
MA
Cityfrown sta�t
1-7 ffe
7
-Telephone-%6ber
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: 7 Cesspool(s) [Zeptic Tank M Tight Tank M Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? M Yes 2No If yes, was it cleaned? ❑ Yes M No
5. Observed condition of component pumped:
6 System Pumped By:
Dave Tine y MasslAA95E ass 1AD31Z
ame Vehicle License Number
B on terprises, Inc.
Company
7. Loca ion where c nt were isposed:
LSD
-Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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