HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 353 PLEASANT STREET 12/29/2024 Commonwealth of Massachusetts
City/Town of
Andover
System Pumping Record
Form 4 JAN 72o25
DPP has provided this form for use by local Boards of Health. Other f6tons may be used, but the
information must be substantially the same as that provided here. Before, osing,"M j's, m, check with your
local Board of Health to determine the form they use, The System Pumping RecoUittm itted to
the local Board of Health or other approving authority within 14 days from *.he purnping date im- f
n
accordance with 310 CMR 15,351. ..........------- ...............
- - -) 11 A.
........... HOUSE: front baccd� rear(!D/rigif
A. Facility Information BUILDING: front back side rear left rig
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1141=3 21 Vstern Owner:
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City town Slate 2 ip C o de
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Telephone Number
B. Pumping Record 6d
1. Date of Pumping 2ale . Quantity Pumped. Gallons
3. Component: Septic Tank Tight Tank
_j Cesspool(s) Grease Trap
Other (describe)
4 Effluent Tee Filter present? 61<19-7-] No If yes, was it cleaned?LD—*es E] No
5. Obsjrved condition o cornponenl pumped:
............ --------------- ............... ...................... ..........
6, System Purnped By.
Dave Tioey Mass1AA95E Mass 1AD31Z
Naine Vehicle License Number
39feson En(erprises, Inc
Company
T Location where contents were disposed:
31-5D
Signature W H
Signature of ReceivIog'Facility (or attach facility (eceipl) Date
l5forrn4,doc- 11112 System pumping Record - page 1 of 1