HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 49 CROSSBOW LANE 3/30/2026 Town
ofAndover
Commonwealth of Massachusetts
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City/Town of _ APR 13 o
26
�Systern Pumping. Record
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Form 4 Health C—
partMent
DEP has provided this form for use, by focal Boards of ficalth Other forms may be used, brit The
nforrnation musk be sut)stantially the same, as that provided here. Before using fhis forn7, check with your
local Board of Health to deterrnine the; forrrl Iheay use;. The Systern PUmping Record must be submitted to
the local Board of Health or other approving raulhorit'y within 14 days from -,he pumping date in
_ -
accordance with :310 CMR 15.35'1 HOUSE: back side
_.. _ .._.... __._._ ____—._ -_-- _-
5A.
Facility Information BUILDING, tuck side rear left 6
Im(,ac,rtant;When
DECK: I_rnde,r
(Illing uul forms t System Location:
� on 117r? Cr>rnp4lPetr,
use only tho (at)
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key to move your Address
f cursof -dry no( IVIA
use the return __—__ r _.__ .__._.__... ---- ....-_._.__._
key cUyfrown State Zip Code
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`7 5 tern Owner:
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NacneiJE,q-1,
Address (it diffe(om from loc.a(lon)
MA
Clly/Town jlule f C.„,,,�zlp ccae
Number
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B. Pumping Record
1, Date of Pumping .. "- ..- _._-...._. 2. Quantity Pumped, ._..._.._
rJ a l e _._..
i Gallons
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3. C()mponent. [ Cesspool(s) eptic `faroy Tight Tank [� Grease CraF.7
Ij Other (describe)!
4. Effluent Tee Filter present? ( ) es �9r
- - f" �> .__ If yes, was It cleaned? [] Yes �)o
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5 Observed condition oir r, omponenl pumped
ytem Pt. ..ped By
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D v�J*ine fv1�s5 1AR95 Z
N,a ra Vehicle License Numb.i —
E39leson Enterprises, Inc.
C'n+tar>ar,y _.
j 7 _bNa(i n where contents were disposed
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Signature, rat Y1avlcr Date
7, >iUi)ra4urra of Receiv{nq f=;r7c1lily (o( ffluc..Yi Idrility rec;r,i(.rl) flak;
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i5lorrN,Ooc- 11112 System fluml)irtg Ftfscord pa)ti, 1 Grf 1
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