HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 154 DUNCAN DRIVE 5/14/2025 Commonwealth of Massachusetts 'Own of No*Andover
City/Town of
System Pumping Record MAY 15 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other forntlQ011 DeWtM nt
information must be substantially the same as, that provided hor(--�, Defore using this form. check 1-9 r�'\70u(
local Board of Health to determine the form) they use. The System Purnping Record must be submitted in
the local Board of Health or other approving authority within '14 days from the pumping date in
accordance with 310 OMR 15,351.
HOUSE: front A—ack i d e rear left
A. Facility Information BUILDING front back side rear lef-i qf�(
Important:When DECK. under
(Illing out forms 1, System Location:
on the computer,
use only the tab
key to move YOLJ[ Address
cursor-do not
LJS8 the return e.41C MA
-C—ityfTown
key, State Zip Code
2. System Owner:
Narne
Inv 0,
Address (If different from location)
MA
CIty/Town —Ste-le -Zip--Code
-Tjie—phone Number
B, Pumping Record
I. Date of Pumpingfat 2, Quantity PL]rnped.
Cal 10—ns
3, Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
El Other (describe): ---------
4, Effluent Tee Filter present? E-) Yes No If yes, was it cleaned? ❑ Yes [] No
of component put-niped,
0 5, Observed condl
6, System PGjmpecl By,
Dave Tln� _Mass IAA95E ass 'IAD312
Name Vehlcie License Numbe
Gnfegon Er)ferpriges, Inc,
Company
7, Lo ion where contents were disposed:
LSD
ignaii-tre of Hauler Date
Tlgn—atureof Rece—lv`IrTf-a—ci—hty--(or attach-faculty-'-- -,receipt)- Date
l5form4.doc, 11112 System Purnping Record Paqp,