HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 SUNSET ROCK ROAD 4/29/2024 L\\ Commonwealth of Massachusetts
Tow n of t lofth Andover
City/Town of
System Pumping Record APR 29 2024
Form 4
Dn' mar m:rat
DEP has provided this form for use by local Boards of Health. Other forms may be used, b�t 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.
HOUSE: front bac ide rear le right
A. Facility Information BUDDING: front back side rear left ri
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, p [
use only the tab Lin$2 � L`
key to move your Address
cursor-do not
use the relurn �• MA �k%q�
key. City own Stale Zip Code
2. System Owner:
rd
Name
A
nnm
Address (if different from loca(ion) .
MA
Cilyrrown Stale Zip Code
Telephone Num-ber
B. Pumping Record
1. Date of Pumping Oale 2 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition.of component p mped:
Ilb r n�c
6. System Pumped By.-
Dave Tiney Mass F5821 ass 1AA95E
Name Vehicle License Nu er
Baleson Enterprises, Inc.
Company
7. on where contents were disposed:
GLSD
k1ki
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Oate
15form4,doc- 11/12
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