HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 136 CARLTON LANE 5/15/2025 Commonwealth of Massach(,isettsAndover
pity/down of
MAY 15 2025
System Pumping Record
Form 4
DFIP has provided this form for use by local Ror arcis of {�irnith. Othunr for ins rn�w be used, but t1�7€������
information niust be substantially lho rsnrne 1s (hit pr<rvicfrd hart--r. E:3eforo using Ihu.�, forrYr, ch rcir wikh y< m
local Board of Health to detern-tine the form M(_,y use. The 7ystern Purnping Record Must be subinMe.cd rra
the Yocal Board of Health or other approving autho(ity within 14 days fron) the purnping date in
accordance with 310 CMR 1.5,351
HOUSE: (::::��a c k side r e a l e f ti' r i��h t
A. Facility Information BL)ILDING: front back aide rear left refs,(
Important:When DFC.K. Uf1C'IPr
riding out forms 1, System Location.
on the computar,
use only the tab _ -
key to move your Adciross
cursor-do not fr�A �& r
use the return `______ __.._____ _._._ __._ _ _
kery. Cityn,own Stare Zip Code
2. S n Owner
Na T)e
Address (ff d'efierent from loci(ion)
MA
Cltyffown Sl a1 0, lip Code
Telraphone NurrlbEar
B. PLImping Record
1, Date of Pur Quantity Pumped
r�pirl0 C7at�� " .. -_.___..._..... ? Gallons
3. Component: Cesspools) Septic Tank E:1 Tight Tank ❑ Crease Trap
F_ Other (describe)
A. Effluent Tee Filter present? E] Yes (� N0 If yeas, was it cleaned? [_-] Yes [.] No
5. Observed condi ' n of component purrrped,
6. System Pi,imped By,
Dave T{neY s 1 A
^Ja r Ve,hlcle l.i urnh -r
eafew F_nfer rises, Inc,
Company___.._.
7 Location where contents were disposed
�LSt)
Slgnafure of Hauler (7are
--_..__._.._.__—__ _._-
_--
Signature of Recelviny'Facility (or attach facilely rF.eeipt) Date
f5form4.doc- 1'1112 ':Ystern Pumping Record t="eft>� 1 cl 1