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HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 100 CROSSBOW LANE 5/12/2025 To Wn Of Commonwealtf� of Massachusetts rthAndover City/T o w n of _.� kAY p 20 Systern Pumping Record - Form 4 a/t DEP has provided this form for use by local Boards of Health. Other forms may be us Nut ut the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Purnping Record must be submitted to the local Board of Health or other approving authority within 14 days from she pumping date in accordance with 310 CMR 15 351 -- r HOUSE: front back sid rear left rigt A. Facility Information BUILDING: front back side r left rigl- ( p Important;When DECK: under UllIng ter,form 1 S stern.Location: on the use oniy the tab ..._____ _ ...._-_--- y y S w- cursor -do not t1r s " l MA use the return __.._ key. kyf-fown scale Zip Code 1 --:1,� 2. SystP,L owner. reurn 'r ___--_.__.._._._----__—._.___. .__.._.._.._--__ Addr©ss (if diflerenl from loca(lan) MA I City�rown slate ZIP Co Telephone umber _..-__------___ B. Pumping Record ? 1. Date of P a rr7 p i n g "-- ----_.. __. _ __._.- 2. Quantity Pumped: - Dale Gallons 3 Component E,_i Cesspool(s) eptic 'rank ❑ Tight Tank (-] Crease Trap E -- (� Other (describe) -_— -------- __. ----.. 4, Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? [D Yes [] h!o 5. Observed condition of component pt.roped: h k 6. System F-1umped By�. Dave Tiney Mass 1AA95E Mass 1AD31Z I Varrir Vehicle License Number Bales0n Enterprises_ Inc. Corr7pany 7. Location where contents were disposed: t G-5D - _ _ --- _ Signature of Hauler Date _. Signature of Fvecfllvirnl F"rACi{ity(of uiY(rir Yr facility rcgeipl) (talc, i t 15lorrn4,doc' 11112 System Pumping Record • Gage 1 of 1