HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 357 CANDLESTICK ROAD 1/16/2026 s �� Commonwealth of Massachusetts Town C)f"Orth AndoVor
City/Town of
Systern Pumping Rocord JAN 2 8 2026
Form 4
DEP has provided this form for use by local Boards of *adtbut the
i)forrnalion must be substantially the s2r-ne as that provided here. Before usingm check with your
local Board of Health to deterrnine the form they use. The System Pumping Record rnust be subrnitted to
the local Board of Health or other approving authority within 14 days from -.he purnping date in
accordance with 310 CMR 15,351, --------------
HOUSE. front ,�ack side rear 67D i
A. Facility Informatiot-I BUILDING: front back side rear left rij
Important:Whon DECK: under
fflifng Out (CHMS 1. System Location:
on Ihe computer,
use only tho tab ----------
key to move your Address
cursor -do no(
........... MA
use the return —-------
key, Chyrrown -Z-1P-e'-0de
2, System Owner:
-------------------............ ----------------
Aodfoss (if differool from loca(lon)
MA
CllyfTown Stale ode
Telephone umber
h,
B. Pumping Record
1, Date of Pumping
2, Quantity Pumped. Gallons
3. Component. Ej Cesspool(s) E9-8�p�i c F a n k Ej Tight Tank ❑ Grease Trap
Other (describe),
4. Effluent Tee Filter present? No If yes, was it cleaned? (es ❑ No
5, Observed condi(ion of component purnpecl:
6, s(en-i Purnped,,By.
a-V-e-T'i n e y I
Mass 1AA9 E Mass 1AD3IZ
------ —------
Name Vehicle License urnber
B Bal�esv Ei)r fpf-ISL' lnc.
C;-ri —a ny
Na
me s v e
,e
oc a
7. ocahon r", tens were sposed�
G L's
L5D
----------
-----------
ii iature W Hauler Date
------- -------------
--------------
gnalu(e of Rec-ivl �aciWy (or altach facility (eceipl) Date
t5lorm4.doc, 11/12 Sys(ern Pumping Record , Page 1 0(1