HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 41 CEDAR LANE 4/20/2026 Commonwealth of Mass'�chusetts Tar a arty Andover
x= r� City/Town of
APR0 2026
System Pumping Record
\`F -f Form 4
He Ith De t
DEP has provided this form for use by local Boards of Health. Other forms may e used,Qgj er1
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
A. Facility information — ----- --�--- BUILDING: front back side rear Ief-t ripw
Important: When DECK: under
filling out forms 1. system Location:
on the only
the tab
, lo-
use only the tab ( �°'
key to move your Addre9S
cursor-do not MA C /S "
usethe. return -----=____.__.._ _.__...... __.___..._ _..__.___ ._ __.__. ..._ _
key Cilyffown Slate Zip Code
2. System Owner:
Name
anrn ,{r
___-f-r-o--
__.--
- Addross (If different from location)
MA
GR'y(1'owr) Stale 2ir>Code.
Telephone lumber
B. Pumping Record
1, Date of Pumping Quantity Pumped:
G)allons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): ------- ---- --_--- ----. __-- _—_--
4. Effluent Tee Filter present? ❑ Yes - No If yes, was it cleaned? ❑ Yes [ ] No
5. Observed condition of component pumped:
i
6. System Ptampeci By:
Dave T i n e Y Mass 1 AA 9 5 E Mass 1 A D 317_
Name Vehlr„le t_icenae ,ber
e a to s o n F n to rp r is es, Inc___-_-- __._-----------_---_.
Company
T Loco ion where contents were disposed:
LSD
Signa of 4Hauler Date
Signature of Receiving facility (or altarh facility receipt) Dale
t5form4.doc- 11112 Systern Pumping Record F>age 1 of 1