HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 10 DUNCAN DRIVE 6/6/2025 No
_ Commonwealth of Massachusetts fthAndoVer
ify/Town of AN
_I" Systern Pumping Recr,�rd '�sza25
Form 4 ...
DEP has provided this form for use by local Boards of Hefakh. O(her loans rn<ay be t,)sP�d,
Information must be substantially the same as lhal provided hero. Before using this forr-T), check will) your
local Board of Health to determine the form (hey use. "The System Pumping Record must be sUbmit(ed (o
the local Board of Health or other approving aulhority within 14 days from the pur-nping date in
accordancewill) 310 C M R 15,351, _-__-_�_.____.--_--_.__..____-- - --_-----.__..---------_--_--_._._.-. ..
IiOIJSE: ffOnC back Side rea e f ht
A. FaclH- y information BUILDING_ front back side rear Ieh rlghl
Important:Whrun DECK unc.leI
filling out forms 1. System Location:
on the computer,
use only Ihci lab
key to move your Address
cursor - do nol f\/IA
use the r e I i r n - -- ----------- --- — ------------ ------ Oy
Cit Town _..__9L_------------___._
key, Y Slalc. Lip code
2. Syst rn Owner:
Nsme
------------- ---- --------_._ .__.---__.--------- --------- -----------------------
Address(If diHereni morn iocalion)
MA -------------- -
Glty own c�lErle Lip Code
Telephone Number
_--._____-.--- --------_..-._-..__.._...__._______.
B. Pumping R�cc�rc�
1. Date of Pumping Dale��� .----------..--- 2., Quantity Pumped. l------.
Gallons
3. Componenl. [] Cesspool(s) Septic "lank Fight Tank ❑ Grease Trap
❑ 0(her (describe) ___ _____.__. _._._ __ _ _._- _-___._._ ._____-__.
4. Effluent Tee Filter present? [J Yes No If yes, was it cleaned? ❑ Yes E No
S. Observed condition of component putnioed.
�drrwa,
6. System Ptjmped By:
0 a v e T I n ey - __.. Mass 't AA D 5 E ass 1 A D 3
Name Vehicle Licenso
Bf�son Enfgr rises, Inc_
Company
7, 0(ion where con(cM,5 were disposed.
D
Jt�/
Signalure of Hauler - — --- -- - - - - --- f)aIe - ---- -- -- ---_ - -__-
Slgnature of Receiving Facility (or attach facility receipt) Date _ --
i5foma4.doc 11f12
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