HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 667 FOREST STREET 4/24/2025 North
` Commonwealth of Massach�,isetts Andover
pity/Town of
System Pumping
y umping Record
T
Form 4 - �� `
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EP has provided this farm for use by local Boards of f-iealth. Other for[ns� may be: used, but the
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information must be substantially the s,arne n.', thit I:arovirded here. Before using lhis form, check with you(
local Board of Health to determine the forrn they use. The System Purnping Record must be subMitted to
the local Board of Health or other approving autho(ity within '14 days fron) the purnping date in
accordance with 310 CM 15.351 � _._.... �
• OrCTI�tIO11 v_._-- ..__.__.___________.__._ ��ICLDIt�1r�. front back side rear ieft ri�trt
__ slCie rea nft right
A. Facility Information €,ht
Ifnportant;When
C7ECK. Wrier
(Ming out forrns 1 Sy Stern l_ocatio 1
on the computer,
use only tho tab
koy to move your Address
L1S8 the (Eitl„!fn
City/Town
key. `dale lip Cade
f 2. S stem n e r
4
Name
Address (if different f(orn localion)
MA
Clty/Town - SWe Lip Code
re�lapho��e r�ur�sUer
B. Pumping Record
1, Date of Pumping P------ --- 2. quantity Purnped �--- .............__..._.
gate Gallons
3, Component: Cesspool(s) ) Septic -Tank [ 'Tight Tar}k ❑ Grease Trap
Other (describe) ___._.__ -.-_.
Effluent Tee Filter preserrl ' 0 Yes., ._._] hoc If yes, was it e ar,eci? [ 1 Yes ❑ lrfn
5. Observed cgnditoon of cornponcnt pw'nped
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6. System Pumped By.
Davy _ . - -- _ 3�Z
Nar}}fe Inc Mach t1Pceose
A,rt�SE -Mass 1A�.,..�
Ba��san enterprises, Inc.
Company
7. tion where contents were dispos(�e d
�aI.SC
r
'ignalure of Hauler Dale
Slgnat u(c of f2ece v'Ing facility (or attacha facility receipt) Date ___..._ _._._.._._ .__._.
l5iorm4.doc• 11112 System Purnpinq Hecord r'r.at t1 1 cal 1