HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 145 CARLTON LANE 5/21/2025 (3) Commonwealth of Massachusetts
Town of earth Andover
I
City/Town of MAY 3 0 2o25
ysfer-n Pumping Record
Form 4 Health DepartMent
DEP has provided this form for use by local Rot-vds of Heal(h). Other fonris may l,)e used, but the
information must be subslanliaily the sarne as lirat provided herd. Before using This form, check with yo u
local Board of He�1I(h to determine late (orn-i Mr;y Th(-, System Purnf)ing Recr, ul rnt.tst be sUr)Mitled to
the local Board of Health or other approvin<) au[lioriiy within 14 days from the pumping date in
accordance with 310 CMR 15,351
---- - -
HOUSF. (r-0 side rear left
A. Facility Inforr-nation BUILDING front back side rear left right
Important; When
DEC.K Ur'1C101
slung out loans 1, Systern Location
on the computer, (fir
use only the lab
key to move your address
cursor - do not
use the return -- ----- -- . -- MA_----- — -- --
4(eY City(rown Stale 7.ip Code
r..._. 2. Sysfern Owner:
J ----- v / #�*"r
Narne
l�
fl<fdrnss,(I(different born loc�Iion)
MI A
Clty/7own Slate lip Code
Telephone Number
B. Pumping Record �~
1. Date of Pumping - 1--------
Dale Quantity Pumped
3. Component; Cesspool(s) Septic Tank ❑ right Tank ❑ Grease Trap
F_) Other (descrihE?)
4. Effluent Tee Filter present? ❑ Yes �J lvo If yes, was it cleaned ❑ Yes [] f,ao
5. Observed condition " f component p(runped
6. System Pumped By
Dave Tlney Mass 1AA95G ass IAD312
Name VohlCle License Numb
PA on Fnjorprisos, Inc
cornpany
71 L on where contents weic disposed.
GL�
gnalure of Hauler Dale
Slgnaiure of fteceiving f acllity (or aPlach farili(y
lra(OMA.dOC- 11117