HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 196 CARLTON LANE 10/16/2025 uuYD u/ o�W«� ��/�U/�
/ Andover
Commonwealth of Mass-achUseffs
OCT � � YO7�
��'f /l- f "� ' � " �"�^
��)�V/ / []��O ��/
System Pumping
Record
'�������� u ����������� ov������
Form 4 r �v ������ Deparfment
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this fonn, check with your
|000| Board of Health to determine the form they use. The System Pumping Record must besubmitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15,351 '
A. Facility Information BUILDING: front bock side rear \eft —Fllht
DECK: under
|mpor�mc�h n
filling out forms 1, System Loo Uo
un the computer,
use only the tab
key m move your Address
cursor donut MA
use the return Code
key, _,[T_' State Zip
i`�Nrll Q1,6 2. System Dvvn
Name
Address(if different from location)
MA
c|tyrrown State z} Coa
f_-,__ �___
B. Pumping Record
1. Date of Pumping 2. Qu@ntity Pumped.
Date lions
�� [�� [� [�
3. Component: �� Cesspool(s) == __pdc Tank �~ Tight Tank �� Grease Trap
[1 Other (describe):
4. Effluent Toe Filter present? 7 YesJ1~<0 If yes, was it cleaned? [l Yes F� No
5. Observed condition of component pumped,
8. System Pumped By:
Dmv T|n Mass 1AA95E Mass JAD31z__�)
Name Vehicle License Number
Bate Bateson Enterprises,_
7, Location vvhena contents were disposed:
Date
lity
t5fvnn4.uoc^ 11/12 System Pumping Record^Page 1o/1
`