HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 133 COLONIAL AVENUE 10/16/2025 Commonwealth of Massachusetts Town Of IVOtth AndoVer
6 City/Town of OCT 1 2o25
System Pumping Record
Form 4 Ith Departrnellt
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.
ri
HOUSE: front back rear left right D
4. Facility Information BUILDING: front "4Ek side rear left right
DECK: under
Important:When
filling out forms 1. System Locatilon: 'au
on the computer,
use only the tab '—Ilz
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
2. System Owner:
x�' Name
Address(if different from location)
MA
Clty/Town State Zj,D Cade
o e
i-telephone Number
B. Pumping Record
2, Quantity Pumped:
—iVA2---
1. Date of Pumping Date Gallons
3. Component: ❑ Cesspool(s) EI—Septic Tank 7 Tight Tank 7 Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 2-lqo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pure ed:
6. System Pumped By:
_Dave Tiney Mass 1AA95E M"ass 1AD31Z)-)
Name Vehicle License
Bat son Enterprises, Inca
Company
7. Location whW.e contents were disposed;,,
GLS "J
Signature Date
-s—lgn—atu—re of ReceivingFacility—(or Date
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