HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 90 SPRING HILL ROAD 11/7/2025 'Own
Commonwealv orb
of Massachusetts Andover
C'ty/Town ofV
Z 4 2025
.? System Pumping m
=_ pink Record
Form 4
Hea"I Depart ,
DEP has provided this form, for use by local Boards of health, Other forms rr,ay be use r e
information must be substantially the san7e as that provided here. Beforp using his form, checl<wifh your
local Board of Health to determine the form they use. The System-, Pumping Record must be submitted to
the local Board of fdeaith or other approving authority within 14 drays fror-n -,he purnping date in
accordance whit 310 C MR 15 351 _- ___ _._ ...
}IC�USC front act side eel Ief-t rigrl
A. Facility intorr-natlot-I SUILDNG: front lack side rear left righ
Important:When (BECK: undpf
filling out forms 1 Systern Location
on they computer,
use only the tab
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B. Pumping Record
1. Date of Purnping Dale _.. —. 2 Quantity Pury)ped:
Gallons
C. Corr7por7errt. [_-_� Cesspool(s) [ Septic rank ❑ Ti l- Tank g ( ] Grease Trap
_
C)ft,er (describe): _. ----___..__
4. Effluent -Tee Filter present? 's NoIf yes, was it cleaned? Yes rIc
5. Observed condition of coi-nponent p urnped: �.
6 S stern Pur7lped By.
-ave l inr y (Mass 1AA95E `Mass 1AD`311
af71e / Vphlclr, License Nurn ,r
Baieson F nferprises, Ina..
C:ornpany
7 Loca(ion where contents were disposed
G SU
Sigroalure of F1<a+.,liar c U'yle. _....
C,
- -.. --- ..... .._.._ _ ----..
Signature-of hec;eivli7<� ( acflity(«r r�Kar,Yz facilely reccipl) CJate
5forrn4 Joc 11I11 System r lm)f:7irrg Recorcf Page; 1 of 1