HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 LIBERTY STREET 4/3/2025 U
Commonwealth of Massachusetts AndoVer
City/Town of
APR 8 2025
S System Pumping Record
Form 4
Heal-it 'E)
DEP has provided this form for use by local Boards of Health, Other forms may b u
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: t�ntack side rear Cleft �ght,
A. Facility Information BUILDING: 6nt ,back side rear left right
Important:When DECK: under
filling out forms 1. System Location,
on the Computer,
use only the tab
key to move your Add
cursor-do not V MA
use the return ------
key. City[Town State Zip Code
ld Q2. System Owner:
Q�
Address--(If different from
MA
CIty[Town
State _ Zip Code
Telephone Number
B. Pumping Record
��C�(�
1. Date of Pumping -bate 2. Quantity Pumped, Gallons
3. Component: 7 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.
.......—-----------
6, System Pumped By,
_Dave Ite Mass 1AA95E '-"I�ass 1A
Name Vehicle License Nuber
eateson Enterprises, Inc.
Company
7. 1-7 afion where contents were disposed:
Signature of Hauler-
----------
Signature of RecelvinFFaC�1111111�-(or attach facility receipt) Date
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