HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 181 JOHNNY CAKE STREET 7/24/2026 ° Commonwealth of.Massachusetts ��:� �a�i'�
Wh Andover
City/Town of
System Pumping Record AVG 2026
Form 4
lealDEP has provided this farm for use by local Boards of Health. Other forms may be us
information must be substantially the same as that provided here. Before usinePda this form,
local Board of Health to determine the form they use. The System Pumping Record be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in with your
accordance with 310 CMR 15.351.
A. Facility information
important:When
filling out farms 1, System Location:
on the computer,
use only the tab "a 1Wa
key to move your Add
susee the return City frown
cursor-do not
n
State 2. System Owner: ZiP Code
Name
Address(if different from location)
City/Town
State Zlp C�_�
B. Pumping Record rele�,umber R
1. Date of Pumping
Gate 2. Quantity Pumped: �
3. Component;
❑ Cesspool(s) RI septic rank ❑ Tight Tank
0 Crease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [J No If yes,was it cleaned?
❑ Yes ❑ No
5. Observed condition of component pumped:
6, system Pumped By:
Name
Vehicle License,Number
Co pany
7. Location ere contents were disposed:
--------------
Sign of Hauler
Signature of Receiving Factility(or attach facility receipt) I Plate
Womn4.doc-11/12
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