HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 80 LOST POND LANE 6/16/2025 Own Of A"*Andover
Commonwealth of Vlassachi.isetts
City/Town of JU/V 16 2025
System Pumping Record
Form 4 j--
i'ment
DEP has provided this form for use by local Boards of Ho,-
Other forms may be used, but (he
information must be substantially the sarne as that provided here. Before using this form, check will) 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 from the pumping date in
accordance with 310 CMR 15,351
—------ HOUSE: front Eck ide rear left(right
A. Facili-ty Information BUILDING. front back side rear 1pf-1 fq,,h(
Important: VVI)an DECK: Lj n d P i
(filing out forms 1. System Location:
on(I)e("Orripulor,
Use Only the lab
key to MOVe YOW Address
cursor-do not MA
use (I)e return 01 SL
key, Ti-iyrro-n lip
W/C"D 2. System Owner
r ve-4
Name
Address (If different from location)
MA
Cly[Town State Zip Code
-Telephone Number
B. Pumping Record
1, Date of Pumping co —------ 2. Quantity Purnped,
3. Component: ❑ Cesspool(s) 17 Septic Tank ❑ 'Tight Tank ❑ Grease Trap
0 Other (describe):
4, Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? Yes No
5, Observed condition of component purnped:
6, Systern Pumped By,
Dave TIney Mass 1AA95E
Name VeTljc"t License N u m b e'l--
Rnfew Enferpris�s, Inc.
Company
7. Loution where contents were disposed:
CaLSD
Signature of Nauler Uale
-------------- ----------
Signature of—Receiving ------- Dale
I5form4.doc- 11/12 System Pumping Record Page i oI I