HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 280 CANDLESTICK ROAD 3/18/2026 <::w
Commonwealth of Massachusetts Town Of N'Ai Andover
�Fx City/Town ofMAR 3 0 2026
System Pumping Record
Form 4 Heakh D
DEP has provided this form for use by Focal Boards of Health, other forms may be used, but the;
information must be substantially the sarne as th<�it provided Mere. Before using this form, check with yow
local Board of Health to determine the form they use The system Pumping Record must be submitted to
the local Board of 1--iealth or other approving authority wiIhin 14 days from the., ptlrrlpincg date;In
accordance. with 310 (',MR 15 351 ---- _
rT1tIC7f1 E3tCJl4��uINC fro f har;l< side r� cft ,ht.
A. Facility Information
it back side. It�ft right
Important; When
DECK: under
filling out:forms 1, System L.ocatlon:
on the cornputer,
use only the tab --2c7C✓ !J—_ ram_ ,,I
key to move, your Address
cursor-do not �(p � MA
UrP the returnC_
key Gily(r"own 3I13te Zip Code
L11
__ 2. SystemOwner:
I f 7
kC _ 7C'�t.w -._..._. _ ._.._. __. . ----------- _.___. -_. ..__. — _..-----
`L N"ir71�!" . ... .
Address (If different from locaOon)
MA
Gity(1-own SIaCe Zif>Code,
Telephone f�lumbwr
B. Pumping Record
� - _ f
'I. Date of Pumping � - � � �uantit� F�(�in�lped�
r.
ylr Gallons
3. Component: , cesspool(s) ] Septic 'Tank C___[ Tight Tank C� Grease Trap
Other (describe): -____.... ._ .._.___. .._____._ __.._. ..........
4, Effluent Tee Filter present? [ ] Yes [ No if yes, was it (,leaned? [_] Yes [ fVo
5. Observed condition of component pu!/mped:
5. System Pulped By:
Dave TlneY_ .__.._.._._.._...___ Mass 1AA95E ass 1AD317_
Name Vehlcle License Nurnbe
eateson Enterprises, Inc.
Company
7, afion where contents were disposed:
GLS
Sig 3 of l'iallle( gale
Siclrratur of f�ere�wln� Facility (or eltrnch facility re.cnif>t) Date -- --
taforrrAdoc• 11112 SYStCfn P urnping Record pggr, 1 of 1