HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 90 WINDSOR LANE 12/4/2025 Commonwealth of Massach isetts n i Andover
G r� City/Town of _
- System Put
-nping Record 152025
Form 4
DEP has provided this farm for use by local Boards of Health, other forms may be u p �2
information must be substantially the same as that provided here. Before using this form, check w gtjr
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,
A. Facility information ��C BUILDING: front back side
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rear left r7"; -'
Important:When DECK: udder
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on the cornoLli r,
use only the tab _� �_ t -n:. '4 .... _.. ....
key to move your Address
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key. CityTfown tate Zip de
2. ystem wner
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Address(if different from location)
MA
Clty(1 own Sa
Code
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B. Pumping Record
1. Date of Pumping
p 9 oi3te _ -- --___.. _.....___ 2 Quantity Pumped. _..._.
Gallons
3. Component: ❑ Cesspool(s) 'eptic Tank Tight Tank❑ Ti
g ❑ Grease Trap
Other (describe):
4, Effluent Tee Filter present? ❑ Yes ZNo if yes, was it cleaned? ❑ Yes [.� i\fo
5. Observed condition of corn' onent pOert�
C�. stem' Purnped By:
a2" Tine
_ _ ..___. Y.__.__. Mass 1 Af 9 5 .Mass 1 A D 317_
Plarne Vehicle License urrk7er
B.
afdson C nterprises Inc
Cornpany
7. oAon whey c 1 q, were disposed:
GL-
Signature of t-tauter
Sf nature of Fiecelv4n f=acili or attach facility receipt) Date
ttiforrt-Adoc• 11/12 System Purnping Record •Page 1 of 1