HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 CRICKET LANE 4/8/2026 ` Commonwealth of Masi Tow"' � �';� �Andover
r
City/Town of
APR 13
206
System Pumping Record
Form 4
' ` ' �
DEP has provided this form for use by local Boards of Health Other forms may be L',sed, TWot
information must be substantivally 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 Bumping Record must be submitted to
the local Board of Health or other approving authority within '141 days from the pumping date in
accordance with 310 CMR 15.351 _ _ _..._ _..___-- __._.._._
A. Facility Information __._. __ ...__._.. BUILDING: front �ac�� side rear left
_ _ 7
Important:When DECI<: under
fllling out forms 1. System Location
on the computer, ( .
use only the tat
key to move your Adrdrn s
— _--
cursor-do not ` MA
use the return
Cil (Town _._
Key. Y state Zip Code
?. System O e
6-1
Address (If different from location)
MA
Cit Y(flown _ __ _ ___ ___
SlaiE Zif>Code; _
Telepf7ane Nur77ber
B. Pumping Record
a1e .._. - - y p4
1. Date of Pumping _._._- ?. Quantity Pumped:
Ions
3. Component: ❑ Cesspool(s) ( ptic Tank ❑ Tight Tank Grease Trap
❑ Other (describe): _...__._ _
4. Effluent Tee Filter present? es 0 r,lo If yes, was it cleaned? es r,Jo
5. Observed condition of component pu,sped
5. Sy err) Pttmp By
ave `f'Iney_. Mass 1AA95EB Mass 1AD31
ame Vr_.hlcle t.iconse Nrrr, .er
e -nter rises, Inc.
Company
7. L (a on where contents were disposed:
LSD
Slynatura of Hauler Data
Signature of Recewlny Facility (or attach facility receipt) bate
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