HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 437 SALEM STREET 4/24/2025 \ Comn'7onwealth of Massachusetts '� ® a Andover
City/Town of
System Pumping m APR
y ping Record rc� 1*2025
Form 4
Hoalth
DEP has provided this form for use by local Boards of Health. Other forms T) the
information must be substantially the same as that provided here. Before using InIs form, check with your
local Board of Health to deterrnine the form they use. The System Pur�nping Record must be submitted to
the local Bogard of Health or other approving authority within 14 days from *.he pumping date in
accordance with 310 CMF; 15.351 _ ____.__ -:.. _.-.
_ — _ HOUSE: front back side ear I, ft rigf
A. Facility information BUILDING: front knack side rear e t rigt
Important, When DECK: under
¢ filling out forms 1. System loCatlUn.
on the computer,
+ e orfly the t
key Y Addrq�o move your ss
cursor
r
use(he etur�I .-- ... ..-. -- ___ _..._.__._ Pv_A_..__._ ___._�.�__._ 4
CIV frown --_�_.__._._._�
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key. Y Sir7(e Zip Code
2. Sy, tem Owner:
�r Name
le7erq '
Address (if different from location)
i
MA
CI(y(7own Stale ✓ Z Code
r
Telephone Number
B, Pumping Record
1. Date of Purnping _. ..... ......... 2 Quantity Pumped _..- - ---__..._.._.___�_
ale G lor7s
3. Component: ❑ Cesspool(s) eptic,xTank ❑ Tight Tank g ❑ Grease Trap
Other (describe): __----..___ ..__.___----_....__._.....
4. Effluent Tee Filter present? 0 Ye _ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of cornponenf pumped:
c
6. System Purnped By:
i Dave Tiney Mass 1AA95E Mass 1AD31Z
Namr' Vehicle license Number
Qateson Enterprises, Inc.
r
Company,
7, location where conte Its were disposed
GLSD _--
dV L
Signature o Mauler .. ...............
I
e-.
w,lttnalurr of Re,r„eivlrig Facility(or allGrcti facility rr;cei(71) Date
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