HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 391 PLEASANT STREET 4/6/2026 Commonwealth of Massachusetts Town of
a ►Andover
max'` City/Town of
System Purnping Record
` = Form 4
Hea
DEP has provided this forr-ri for use by local Boards of Hearltlh. Other forms rn PgPildmient
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,. "Fine System Pumping Record must be submitted :o
the local Board of Health or other approving authority vvithin 14 drays from the pumping date in
accordance with 310 C M R 15.351
HOUSE: front ack ide rear left 71f;ht
A. Facility Information [iUILDING: front back side rear left rirht
important: WYiE;n
DECK: uncJei
((Mince out forms 1. system l_ocic1 5r :
on flare:lythrlaf�iler, 3 C?/, e,.
use only tk1r3 (at7 / /// -_---- - _. ._.-.__... _...,__.,...--._..... - .. - ---- -
key to move;your Address
cursor-do not
use the return MA
key. cityfl,own State Zip Code
Syst@m o ner:
�v ,t `�
__ ____ ........___
Name
tick
Address (if different from location)
M A,
ty/Town Si ate �" tG Code
Telephone Nurnbear
B. Pumping Record
1. Date of Purnping _. __.- 2. Ouantity Pumped -
Dale Gallons
3 Component. l(1) Tight fr1k Grease Trap p
�_--� Other (eJesrribe):
4, Effluent Tee Filter present? (_.) Yes No If yes, was it cleaned? ❑ Yes hJr1
5. observed condition of cornp rent put .7ed�
6. en' P_0 n p e d By
f
Dave C Ine:Y Mass, I AA95 Mass 1 AD317_
ame \O hlc.le L cE nse umber
.. Enterpriscs, Inc, _..._...,...__.... ...
7. L .Cion vvhcere c tear s were disposed:
GLSD
Signature of i laulcr C)at
Siyr'aetrr�t, fret Div�7r �Tci ity or aaltac h ,agility rust, {>t) Date
t5forrn4,doc- 11/12 System Purnping Recor(,j ' PEJge 1 of 1