HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 311 DALE STREET 4/24/2025 Commonwealth of Massachusetts orn o�ro Andover
�r_= City/Town of
tla System Pumping Record APR
7
Form 4 �25
DEP has provided this form for use by local Boards of Health. Other for(N` the r k>ut the
information must be substantially the same as (hat provided here. Before using IN f � ow
local Board of Health to determine the forn'r lhey use. The System Pumping Record must be sub ml uo
the local Board of Health or other approving authority within 14 days from the pumping date io
accordance with 310 CMR 15.351 --- --- - -
_._.._— _ HOUSE: (front-Yack side rear leftC',
ght
A. Facility Information BUILDING front back side rear tell
Important:When DECK: i_1ncfer
filling out forrns 1 System Location:
on(he computhe tab
use onlythe
9`1 MA , y
move
City/Town r{
cursor_do not
use the -- —. _. ---- ---- ----
y Y
key, Slate Zip Code
to/ r� 2. Syµ ��ner: T
F� Name
Address(If different from location)
MA
CltyrTown State d Lip Code
Telephone Number
B. Pumping Record
1. Date of Pumping --L&( - 2 Quantity Purnped
Date Gallons
t
3, Campanent: Ces6pool(s) Septic -rank ❑ Tight Tank
❑ Grease Trap
Other (describe): __ .__.._...----------—- ---- ----— -- ---- - - --
4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? [] Yes ❑ No
5. Observed condition of cornponent pumped:
6. System Pumped By: _.._,_,
Dave T l n eY_—_____.____ Mass 1 AA A 5 E Mass 1 A D 312-
Name Vehicle Lir_ense Number —
eafeson Enferpriges, Inc.
Cornpany _
7. %�,
on where contents were di5po5ed.
§Ignalure of Hauler Dale
Signature of Receiving Faciilry (or attach facility receipt) Date
l5forrn4.doc, 11112 System(lumping Record Pacts 1 0l 1