HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 386 SHARPNERS POND ROAD 11/12/2025 Commonwealth of Massachusetts Town 0,"s,fh AndoVer
a City/Town of
NOV System Pumping Record 20
Form 4
Health
BEfo has provided this form for use by local Boards of Health. Other forms may be us Mjw
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 _.- _-- __.._. __.. __.—_._
HOUSE: ron�,—)back sid 'rear left rigs`
A. Facility information BUILDING: front back side rear left right
important:When DECK: under
filling out forms 1. System L,ocatio
on the computer, t
use only the tab -Address� _
___. _ . ._-.__ -_
key to move your
cursor-do not /np// MA
use the. return — _.._.__._.._ __.._._._.--.._—�-- — _�__.___ Zip Code
,y cityrrown Sfete___._.._ __..._ _._ _
2. System Owner:
Name
gran�
Address (if different from location)
MA_
CitylTown Staff Lip Code
Telephone Number
B. Pumping Record
--- --- C
1. date of Pumping 2. Quantity Pumped: --!--
Gallons
3, Component: [] Cesspooi(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
0 Other (describe): _ _..__._. ._..______.__--
4. Effluent Tee Filter present? F] Yes Et-FN"o If yes, was it cleaned? ❑ Yes Na
5. Observed condition of compon nt pumped: rr
�L "I
6. S stem Pumped By:
aveTlneY -- .-_- -. Mass 1AA95E Mass 1AD31Z_
me Vehicle License Nun'iber
Meson Enterprises,_Inc
Cornpany
7. &ocaionherecos were dispos€;d _._.--..._
-. ..... _
_.__ . __..._.. .. __-
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11/12 Systern Pumping Record •Page 1 of 1