HomeMy WebLinkAboutSeptic Pumping Slip - 2025-02-07 - Septic Pumping Slip - 54 OLD CART WAY 2/7/2025 Commonwealth of Massachusetts TOM of INA Andover
City/Town of FEB 18 2025
System Pumping Record
Form 4
Heallth Department
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 fror-n the pumping date in
accordance with 310 CIVIR 16,351,
HOUSE: front back side rear eft
right,
BUILDING: front back(:�
A. Facility Information slPe rear le t right
Important;When DECK: under
filling Out forms 1. System Location:
on the cornf)LIt8f,
use only the tab
key to move your Address
cursor-do not �3 MA
use the return ---------
key, City/Town Zip Code
1421::] 2, Systqrn Owner:
IOWA
Address (if different from location)
MA
Lip Codee-"
CItyrToWn ate
-feTe—p'hone umber
B. Pumping Record
1, Date of Pumping 2, Quantity Pumped, xw
Date Gallons
I Component: ❑ Cesspool(s) r--V'Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ L/
Other (describe):
4, Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? Yes [] No
5. Observed condi I'd of component pumped,
-------------
6, System Pumped By: Mass Dave TIney M2SS I AA95E MIAD31Z
Vehicle. License !�Lr
.eatescn Enterprises, Inc,
Company
7, -L-a-c*,ion where contents were disposed:
-(3LSD ..............
Signature of Hauler Date
Signature of Receiving Facility lot) Date
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