HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 129 CHRISTIAN WAY 5/11/2026 Tow
Comnionwealtr-i of Massachusetts n of NMh Andover
r1 City/Town of MAY 15 2026
System Pumping Record
Forrn 4
Health Department
�r r
DEFT has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the sarne as that provided here. Before using this form, check with you(
local Board of Health to determine the form they use. The System Pumping Record must be submitted t(,)
the local Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15 351
i- 0USE: fr t bark side rea haft` right
A. Facility information E�UII.DING: tront back side rear left rlt,;ht
Important:When DECK: under
Oiling out forms 1, System Location:
on the cornp(iter,
use only the tat)
key to move your Address
cursor-do not
use the return —' —_—._____.._.._ ___ _._ __._.__.__ I�� ....__-- ---..__._ __-----._
Key. Cityf'rown State Zip Code
2. System Owner:
fNan ---— ----___ ._____-------
Address (I(different (rorn location)
MA
S(aie - _.-._ __..__. _.__._._
zip Code __..
7eie hone Number
B. Pumping Record
1 ------._.__-___
1. bate of Pumping -bale /r 2. Quantity Pumped: --
C,allons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
g J Grease Trap
❑ Other (describe): ----___—------- --___-...
4. Effluent Tee Filter present? Yes (—) No If yes, was it cleaned? Yes ❑ ado
5. Observed condition of cor ponent pumped:
6. System Pumped By:
Dave Tiney Mass 1 AA95 Mass 1 AD317_
Na1Yl C' Vehirlr l.ir,.e n,, urnbe,r
Bateson Enterprises, Inc_
Company
7.4.�) r
where CUntenCS were d15(�oSPC1:
amer Dale
Signature of F,eceiving f-ecliity (or aft»rh facility rr;ceipl)
t5form4.doc• 11t12 Systcrn Purnping Record •Page 1 of 1