HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 300 FOSTER STREET 3/11/2026 Commonwealth of Massach�isetts clf No*Andover
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System Pumping Record
Form 4 nA
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DEiP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 (o
the local Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15,351
NCJUS[: front"back side rear efts rif;ht
A. Facility Information BUIt_DING. front back side rear left rip,ht
Important: When DECK: under
Wiling out forms 1. System I_oca Ion:
on the computer,
use only the tat
key to move your Address
cursor-do not MA
Ilse the return --- ----- - _... _ ___.. ----- --
Cit !Town �, --- _._._______ __..-._.
rey Y State Lip Code
2. Syst4- 44"'4
Oer:
_ --
J i Name
eerWn f I t�j
Address (if different from location)
MA
Ciky!'Town SIafF � Zip C;ocie
1"e t7 - ---
leph-one Numer —
B. Pumping Record
1. Date of Pumping Dale - --- 2. Quantity Pumped " --_--------_.-----._.__._
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
9 Grease Trap
❑ Other (describe): ----.--______
4. Effluent Tee Filter present? Yes ❑ hfo If yes, was it cleaned? Yes ❑ No
5. Observed condition of c rnponent pumped:
//C� . e
6. System Pumped By:
Dave TIneY�..____---- Mass 1AA95E ass 1AaD31Z
------
Name Vehicle License Nr,mbe
Bateson Fnterprises, Inc.
Company
7. Lgcation where contents were disposed:
GLSD
Signatur of I uler Date
Signature pf F7eceivlr7g Facility (or attach facitify receipt) pale --"
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