HomeMy WebLinkAboutSeptic Pumping Slip - 129 Christian Way - 2025-02-12 - Septic Pumping Slip - 129 CHRISTIAN WAY 2/12/2025 I
Town oj Noll Andover
Commonwealth of Massachusetts FEB 18 2025
City/Town of
System Pumping Record
Form 4 Health 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 from the pumping date in
accordance with 310 CIVIR 15.351.
HOUSE: ran back side rear left)right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab J�-_
key to move your Address
cursor-do not MA
use the return
key. CA)/Town State Zip Code
2. System Owner:
r rob
&_Ae
Name
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped'. h56 6
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
El Other(describe):
4. Effluent Tee Filter present? yes No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tlne Mass 1AA'96E5 Mass 1 AD31 Z
Name Veh��mber
Bateson Ent! rL(isqs, Inc.
Company
7. tion where contents were disposed:
GLS
...........
Signature of Hau`ler
Signature pf Receiving`Facility(or aEachfaciifiiiecefpt)—------- Date _
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