HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 623 OSGOOD STREET 11/14/2025 Andover
Cammanwealth of Niassachusatts Town of
< f City/Town of NV 201
P. System Pumping Record
{ r=:- ,• Form 4Health °
DE•wP has provided this form for use by local Boards of Health. Other farms may be used, but the
information must be substantially the same as that provided here, Before using this form, check with your
focal 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 frown the pumping date in
accordance with 310 CMR 15.351.
n back
ide
ear left
A. Facilityinfornlatior7 BUILDING:NG: front back side rear left rif,P�1t
r;,t
important: When DECK: under
filling out forms 1. System Location:
on the cornputer, / *�
use only the tab --
-. _
key to rnove, yor.rr Address _
cursor-do not
use the return __..... .__._ _ ._ __.._.__ .. ___.. . ---._..__,_.. __—___ MA __--
key. City/Town State Zip
. ._..__ 2. Sy
stem Owner:
`�.,,'- _ ......._. _._._ ' _...._._felts.. �.�.............-__.__._._. _.. ....._............ ._......_-------._...__....._._..._..---..._._ ------------ __.__. ..._._ ......_....
reran �0-
Address (if different from location)
MA
Telephone Number
B. Pumping Record /
1, Date of Pumping ( .. ._.._._ 2. Quantity Pumped: --_�� _.._..-_--____.__.
ate y p Gallons
3, Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Crease Trap
[_] Other (describe): _.___ _.-,_____—__.___.
4. Effluent Tee Filter present? ❑ Yes/No If yes, was it cleaned? E] Yes ❑ No
5. Observed condition ofcomponent pumped:
5. System Pumped By
f0aveTlrlcy assAA9
15E _Mass 1faD31Z
dame Vt,hlcle Lice � umber _.__
Bateson Enterprises, Inc.
Gorripany
7. L - tion where contents were disposed:
GLSC7
X .... . ...-..
Signalure of Hauler Dat
e ______ —___..__.__-__--
Segnature of Receiving h-aciltky(or attach facility receipt) Dtatrr� - -
t5form4.doc- 11/12 SystoM Purnping Record -Page 1 of 1