HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 248 REA STREET 3/9/2026 Town of h Andover
G nu Commonwealth of Massachusetts MAR 16 2026
- City/Town of
a System Pumping Regard Health Department
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the sarne as that provided Mere. 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
A. Facility intormatloCl — - 3UtILD NG: front back side rear left righ r,r
Important: When DECK: under
filling out forms 1. System Location:
on the computer, r
use only the tab ,
key to move your Address
cursor-do nolc Mf
use the return __ _---..�_ __.—_--._.. _.-_..__,. —_ .._ . ___ _..._______:_._
key. ,ityrrown 'S tee Zip Code
2. System Qwner:
, ,^ .
\� X
Name - - - - - --- -
-,jll�
_ y
Address (if different frorn location)
M AI
City(1'own —�_— __._..__ _.___.__ ----__. _.__---- Strain Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dale- -----__._. -_. 2. Quantity Pumped: Gal tons --------
3. Component: ❑ Cesspool(s) Septic -Tank ❑ Tight Tank
g Grease Trap
❑ Other (describe) _ ---— -- ------- -- —---_.- -- ----- -- —_ ---- -------
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? [_] Yes No
5. Observed condition of component purnped:
6. System Pumped By: M
Dave They____----___- .__. _.__—___ Mass 1 AA95E ass 1 AD31 _
Name Vehicle; license Nurr,be
Bateson Enterprises, Inc,
Company
7. on where contents were clisposed,
GLS
Sig iurc3 Hauler Date
Signature of Recewing Facility (or attarh facility receipt) Dale -----_
t5form4.doer 11/12 Systezrn Pumping Record • Facie 1 of 1