HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 105 BROOKVIEW DRIVE 1/28/2026 Town North
OfAndover
` Commonwealth of Massachusetts
c r 'rz City/Town of �
- System Put
JAN 0`p yaping Record
Form 4
De
DBP has provided this form for use by local Boards of Health. Other forms rney be use , bu r:;
infort-nation must be substantially the sarne as that provided here. Before using Ihis 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: front ide rear Ief-t right
A. Facility Informatiorl BUILDING: front hack side rear left right
Important: When DECK: tjriC'Iel,
011ing out forms 1, System Location,
on(he cam utor,
p
use only the Cab
key to move your Address
cursor-do not MA
use the return _.__. ___........ __ ______.. _._
key. City[Towo State Zip Code
Y
2. System Owner:
— -- Xr_r-_—
� Name .. __..
Address (if different from location)
MA
CityrTown Slate Zip Code
Telephone Number - C
r
B. Pumping Record
1. Date of Pumping Dat�a ? "
Quantity Pumped:
Gallons
3. Component: Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
[] Other (describe): — -_.___._..____._. _-_ __._.___.__._.._--
4. Effluent Tee Filter present? ❑ Yes _ No If yes, was it cleaned? ❑ Yes F No
5. Observed condition of component purnped:
6. System Pumped By,
Dave m_._ _.... ass '1AA95R'� Mass 1Ab31Z
Name (V7ehlcle License-tJ k]er __...__...._..
Bateson Enterprises, Inc w
(foml>arry
7. i n where contents were dispersed:
GLS
Signa re Hauler Date
Signature of Receivi ng Facility (or attach facility receipt) [late
_ .
t5form4.doc• 11/12 System Pumping Record -Page 1 or 1