HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 260 CANDLESTICK ROAD 5/15/2025 Commonwealth of Massachusetts Town of ®rah Andover
-y City/Town of MAY 3 0 U25
System Pumping Record
r
-- Form 4 Health Department
Lam%
DEP has provided this form for use by local Boards of Health, Other forms may be used, but(l)e
information n-rust be substantially the sarne ra lhat ofovicied hare. Refore using This form), check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days iron) the pumping date in
accordance with 310 CM 15,351,
A. Faculty Information BUILDING front ck side rear lef ht
- — ----- -- ------- -- HOUSE: front ba
- back SiCip rest left right
Important;When
r der
nlling out forms 1. System Location
on the computer,
use only the lab _— -----.—� �4 - __
key(o move your Address
cursor-do no(
use the return MA
key, Cilyffown Slate 7ip Code
2. System Owner:
Name
L—�W
Address(If different from location)
MA
city/Town SIa1e-^—____ ___—_— _ Zip Code
��� --
Telephone NUrnber
B. Pumping Record /
1. Date of Pumping t7aa � ------ 2. Quan(ity Pumped �� ---------.__...
Gallons
3. Component: ❑ Cesspoo)(s) Sep(ic Tank ❑ Wight Tank (] Grease Trap
❑ Other (describe): -- .__.___- __.-_--
4. Effluent Tee Filter present? [_] Yes No If yes, was it cleaned? [..) Yes No
5. Observed condition of component purnped
xArm
6. System P4imped By.
Dave Tlney Mass 1AA95E Mass 'IAU31Z
Name Vehicle License Numb
Baienn Enter rises, Inc.
Company
7. L o-"-U'on where contents were disposed:
GLSO
611
Signature of Hauler L)ale
Slgnature of ftecelving hacility (or attach facility receipt} Oats --—`- -- ---- -
Worm4.doc- 11112 System Purnping hecord • page 1 0r 1