HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 163 CANDLESTICK ROAD 4/22/2024 Commonwealth of Massachusetts TyAti,,� Andover
City/Town of 1(lor- w , Y)cia�It'_
System Pumping Record APR 2 2 2024
Form 4
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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, ` (_ `L Ca�r1 cI t S 4.i c y— `n„
use only the tab �Y J � 1 l V KN
aj-
key to move your Address cursor-do not &iv r Th AjAddver _AAA Q l c l S_
use the return Citylrown State Zip Code
key.
�m
2. System Owner:
:�n h �1 e
Name
reNn
Address(if different from location)
Cityrrown State Zip Code
ct)�-5 — _3Q.,
Telephone Number
B. Pumping Record
1. Date of Pumping q/Z /2u 2. Quantity Pumped: 000
Date Gallons
3. Component: ❑ Cesspool(s) E�Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? [(Yes ❑ No If yes, was it cleaned? �es ❑ No
5. Observed condition of component pumped:
Lcyod
6. System Pumped By:
' 'e_/rem�A
Name Vehicle License Number
Company
7. Location where contents were disposed:
LU I(R n Lf
Signature of Ha er Date
Signature of Receiving acirdy(or attach facility receipt) Date
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