HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 WINDKIST FARM ROAD 1/28/2026 Coc�� i-nonw� alth of Massa�;huse�ts Townul' Yofth Andover
JAN 2 8 2626
System Pumping Record
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_ Form 4
Hea Departmen
' _ 3oarcPs of Health, C P1 f h ,DE=1� has provided this fort°n fof use. by local E� Other vrrns may be used, bu( he
nformation rnust be s. ..Ibstarlh ally the same as fh7f provided here Before using this form, check wlkh your
focal Board of Health to de(em-)ifle the; four They use, The Sysiern Pumping Record rn ust be, subml("ed (o
the local Board of Eleelth o� other approving au(hoiity wi(hin 14 d3ys frown to pumping date in
accordance with ',1 t5 1. MR 15 151 .._.....
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/ Facility Informatiot7 S )cNG front back
rcar raft" r
side rear 1e"ft r
Important:Whcin
(:'> (�K: under
Uning out forms 1 b( t y" e`n ( t74,cr I lio
on Ole cornpulw, ' ,
1p Cd s
eauY do move y Ufn fps- -) ", � ..
- us
r;ursor do no(
use the reluin (. - u" - MA
k¢.y. y stl 31 y Zip Code
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AUdrays (If rlEfis;ron6 from', Incnll¢>n)
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rf Ipt}rrr7� irr7.,�fC
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B, Pumping ReCC7rCi p
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1. C., _-�°,_ ) "�' 2 Quantity E�ump��d.
Date r�( f:�l.arn�Ir7r ---.__-.
Gallons
:3. Con,iponc,rlf. �_� � C:essPr�ol(s) e;raliC han [_� 'rigf
li Tank �_� Grease -(-rap
C__) Other (describe)
4. E ff Iuent Tee Filter pre;sent > �(,, � F I If yes, was it cl(32ned7
5 Observed (,undition of corn[ onerll L>l.(rrape(a
y,rl
y By
�we''_rin - Muss 1AA95Ew (Vlass 1AD31Z
arnr't V YurJe tkensr tsiurnber
��i `son E17lF�rf�ri�;��s, Inr..
C,nlrlpany
l. I b- Mahon wil ( to tt r.l.s-wt,rt di } ri5 d.
G L 3 D
:7ug Date
`>Ignaluro C,I Evr,'yc,c(vl)t) Facility(or rrll,rr.li (ar.ilily rr;r,ri(rl) Oate, _ --
1
5(t�rrn4.OUC l'iti2 `�oyslcIM Pumping Rr;Co((,f p,,3(t„ 1 0l t