HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 57 OLYMPIC LANE 4/24/2025 Town 'f
Commonwealth of Massaoh(.asi ndover
City/1own of APR 202
System Pumping Record
v p gr
Ment
F o r r'n 4 ;' `
DE P has provided this form for use by loca{ Boards of [iealltt�r. Other fo ns rnaly I:)e, used, bul the
information must be substantially the same 1s lhr t provided here. Before, using This form, check with yorir
local Board of Health to determine the form they use. The System Purnpiing Record Must be suhmltled to
the local Board of Health or other approving aull-to0y within 14 days fron) th'e purrlping date in
accordance with 310 (AMR 15 35q
-.__. f-oUsf. front.. bac side rea ef't ripr,t
A. Facility Information BUILDING: front back side rear lef-t right
Important: Whan DECK: Under
Oiling out forms 1 System Location
on fhe cornnuler, /may
use only the tab � - � (�(C d7
keV o move;your Address
cursor-do not ,
use the return —___._ _.. ____-..-__. __._ ____...._ _. .__..___ MA_-----__
key. City/Town Slate Zip Code
' 2. Systern Owner
' k
Name
Address(If different from Iocalion)
MA
Clty/Town Slat(" Zip Code
cc -,
1'F, phone Number
.._ .._,_u. —..__
B. Pumping R�corci
1, Date of Pumping Quantity Pumped
[late C,allans
3. Component: ❑ Cesepool(s) Septic 'Tank [ 'Fight Tank ❑ Grease Trap
[] Other (describe)
4. Effluent Tee Filter present? [.� Yes ) No If yes, was it cleaned? El Yes o No
5. Observed condition of cornponent puinped:
6. Systern P4tmped By:
Dave Tlney -_.___ _- Mass 1 J�A95E- Mass 1 AD 1`9
_ ._-----------__. _. _--- _ ______
i,lanio Vehicle License, NU 7hrr
@afescln Enfervii es, Inc
Company
7. tic�n where contents were ciisposr, d
(a��U
........._...--.--
Signature of Hat.rler [:)ate
Signature of F pcelving facility or attach facility receipt) Gate -
t8forrn4Aoc, 11/12 Systern Pumping rdecorrf Page; 1 01 1