HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 FARNUM STREET 4/24/2025 Commonwealth of Massach(isetts rOIAln Of'VOrth Andover
City/Town of APR 28 2025
System Pumping Record Depc-jrt,,,t
Form 4
DEP has provided this form for use by local Boards of Health, Other forms may be used, but (he
information must be substantially the same as that provided here. Before using This form, Check with you(
local Board of Health to determine the form lhey use, "The System Pumping Record Must be submitted to
the local Board of Health or other approving authority MIND 14 days from the pumping date in
accordance with 310 CMR 15.351 ------
HOUSE: front (Ea2c )sidp rear left right
I F)
A. Facility Information BUILDING front back side rear left rif,,ht
Important; Whort
(Illing Out forms 1. Systern Location
on the COMPUtPr,
use only the tab
key to move your Address
cursor-do not IAA
use the return
Tkey. ,tylfo—wn- state Zip Code
2, System Owner
0 cry QC 16-n C-
--J
Address(If difierenl from localion)
MA
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Clty/Town Sfate 04 s - Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping 2 Quantity Pumped:
Date Gallons
3, Component: El Cesspool(s) Septic Tank F.7 'Tight Tank Grease Trap
[] Other (describe): ----------
4, Effluent Tee Filter present? 0 Yes NO If yes, was it cleaned? ❑ Yes No
5, Observed condi 'on of cornponent purnped,
6. System PQrnped By:
Dave TIney Mass 1AA95E/,-' M2SS 1/VD37Z--,
(�-a nn o Vehicle License, li er
gifew Enfprprises, Inc.
-
Company
7, oc 'on where contents were diSlD05cc:
..............
4?
Signature of Hauler Dale
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-�-IqaTu(e of Receiving F`�ac�llit)y (or attach facility receipt) Dale
i6form4.doc, 11112 System flurnping Record paq, 1 of 1