HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 795 JOHNSON STREET 12/30/2024 "4'
Commonwealth of Massachusetts Aje OrthAndover
City/Town of JA N
System Pumping Record
Form 4
9P2 DEP has provided this form for use by local Boards of Health. Other forms MOP�* but the
information must be substantially the same as lhat provided here. Before using this check with your
local Board of Health to determine the form lhey 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 back side(re)arej rig[
A. Facility Information BUILDING: front back side rear left rigl-
Important:when DECK: Linder
filling out f0fM9 1. S tern Location:
on the computer,
use only the tab
key to move your Af1dress
cursor -do no(
use the return MA
key fl,4y "o-�- Slate Zip Code
14 ul— Z. System Owner:
e V/1 iuj
a M
Aodre8s (it different from locatlon)
MA
ltyrTowo Slate 11 �Code
Telephone Number
B. Pumping Record
Bumping
1. Date of Fur Quantity Pumped —ale '
3. Component: Cesspool(s) j�Septic Tank ❑ Tight Tank ❑ Grease Trap
E] Other (describe),
4, Effluent Tee Filter present? [3 Yes -Z- No If yes, was it cleaned? [] Yes [] No
5. Observed condition of component p unnpe I
6. System Pumped By.
Dave Tiney Mass 1A-A95E Mass IAD31Z
Name Vehicle License Number
Baleson Enterprises, Inc.
Company
7, Location where contents were disposed,
GL5D
Signature of riauler
ate
...........- --------- --- ----—------
Signature of Receiving'F acility (o( al(,acf-) (,aciiihy receipt) Date
15form4AOC, 11112 System Pumping Record- Page 1 of 1