HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 186 CANDLESTICK ROAD 10/16/2025 Andover
Commonwealth of Massachusetts
y City/Town of
x = System Pumping Records e
y Form 4
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 form, check with 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: fr�nj'back side rear le right,
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important;When
use only the tab _ �n
fillingout forms 1. S—�tefTi
y o al t
on the computer,
key to move your Address
cursor-do not MA —
use the return key. City[Town State Zip Code
2. S stem wner'
4� j
y Name
` —.---___-_--
Sawa �i)
Address(if different from location)
MA
Clty[TOwn State Zip Code
7elephane Number
B. Pumping Record
1. Date of Pumping --_ ------- 2. Quantity Pumped: �---- -------
Date Gallons3. Component: (❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
i
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? [ ] Yes ❑ No
5. Observed condition of component pumped;
lk/
.I
6. System Pumped By:
NDave Tlne� --_._ _.. _----- Veasshlcle 1AA9Licens Number
Mass IAD31Z�
Bates'ran Enterprises, Inc.
Company
7. Location where contents were disposed:
G ---_qD
ture of Hauler _---- -r Date �--.___�._.---
Signa
Signature of Receiving Facility(or attach facility receipt) Date
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