HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 557 BOXFORD STREET 11/20/2025 Commonwealth of Massachusetts T0111n Of Wilh AndoVer
City/Town of
a
System Pumping Record NOV 2
,• Form 4 OZ
5 e p
DEP has provided this form for use by local Boards of Health. Other for
information must be substantially the same as that provided here. Before using this f rm, h 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: ront b-ck side rear left riphr
A. Facility information BUILDING: Off't back side rear haft right
Important:When DECK: under
filling out forms 1. System Locatio
on the computer,
use only the tab
key to move your Address
cursor-do not �C MA
use the return ----__ _____ _ __.._ _ __ ( ._..__--.-______-_ __-_
key. Y State Zip Code
c� r� 2. Sys em Owner:
0-f Cj_'-e 'S'
Name
Address(if different from location)
MA
City(Town State .-----
Zip Code
Telephone Number
B. Pumping Record
1. Date of
-Pumping
. _..___-. _ �^ -
jC C
p 9 oate— _._.______ 2. quantity Pumped.
Gallons
3. Component: ❑ Cesspool(s) [septic Tank ❑ Tank Tight
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes P�No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of c cn onent pum d:
11
rv..
6. ysten Pumped By: -.
Dave Tiney_ Mass 1 AA95E ss�1A D 3 1 Z 1
Nameso V e h I c I e Ucense Num
e f"erprises, Inc
rnpany
7. Loa wher, c n-ten s were„d.isposed.-
GL D
Signature of Hauler Date
----------__--
Signature of Receiving Facility(or attach facility recelpt) C ate -- -
t5form4.doc• 11/12
System Pumping Record -Pale 1 0(1