HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 103 BRADFORD STREET 7/24/2025 _ C o row/7 Of/V
mmonwealth of Massach(,Isetts rt/�
City/Town of
Andov
System Pumping Record AUG112025
e4, Form 4 � �
DBP has provided this form for use by local l3orardc> of Health. Other (orrns may b��>��
information must be substantial) the same as that ec'
y providers h re 4=3efore i.,sing this form, check lh yor.ir
local Board of Health to determine the form lhey use. The Systern Pumping Record must be submitted Io
the local Board of Health or other approving autho6ty within 14 days from the pumping date in
accordance with 310 CMR '15,351
-------�__.— H0USF_. front ack side rear 1e rip'hl
A. Facility Information BUIt_DING: front back side rear Ieh
Important;When DECK'. under
Oiling out forms 1. System Location.
on the computer, r7
use only the tab
I<ey(o move your Addre" s
cursor -donot
use the return MA
key, Stale otle' Z - -- - --
2. Systern Owner
SFr f�7ama ___.
unrn �'
Address (If different from location)
MA
CI
—._(y--JTo---wn.__-.._----- Sta_a I
le Lip Code
_ - ;.-
Telephone Number
B. Pumping ReCorci (/
1. Date of Pumping 2 d ___-__.
F � O a l e _..._ _.._ .- 7. C)u 2 n t i t y Pumped.
Ga ns
3. Component: ❑ Cesspool(s) Septic Tank ❑ "Tight Tank ❑ Grease Trap
Q Other (describe) - --------._ __---_._----------- --------- ------—--- ----
4. Effluent Tee Filter present? [] Yes -_] No If yes, was it cleaned'? [__] Yes ❑ No
5, Observed condition of component pumped:
6. System Prjmped By:
Dave Tlne Mass 1PA95E Mess 1AD31Z
Name Vehicle License glum er
ga wn Enter rises, Inc_ _
Company
7, s�a 'an where contents were disposed:
L .
signalure of Hauler Dale _...
SI nature of Recelv)n, Fa M —g g ty (or attach facility receipl) bale
15(orm4.doc• 11112
System Pumping Record Pane � r,r 7