HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 95 CARLTON LANE 6/3/2026 Town f orth n
` Commonwealth of Massachlastts Andover
=I C'ty/Town of JUN
. s zazs
tam Purn y p nr� Record
Form 4 Health
DepartMent
DEP has provided this form for use by local Boards of Health. other forms may be used, but the
nforrnation must be substantially the saute as that provided here. Before, using this form, Ctleck with your
local Board of Health to determine the fom-) they use The System Pumping Record must be submitte,j to
the local Board of I-iealth or other approving authonty within 14 days from the pumping date In
accordance with 310 CMR 15.351 ___.-_ -------- _ --
_.____ ........ H01,.J`I front act< side
side rear left r�PhI
A. FacilityInforr-ration BUIt.DING front back r,t
lfnportant:When NECK: under
(Illing Out(owns 1. Systern Location
on the cornputer,
use only the tab
!«y Io rnove�your Address
cufsor •do not
use the: return MA
Key. CityfT'own ;31arn to Cote — — —
�--- 2. System Owner:
N8rt1r
Address (if different from location)
City(hewn -_-
M P,
^Zip Code
Teleph c r-urnnbp_..0
r
B. Pumping Record
� _.^- _
1. Date of Pumping Da� "�' �` � � - 2 Quantify F'urnped�
3. Component: C J Cesspool(s) [] optic Tank ❑ Tight Tank
Grease Wrap
Other (describe); . .._
4. Effluent Tee filter present? ❑ Yes If yeas, was it cleaned? (-.) Yes [j No
5. Observed condition of component pur7lped.
6. System Pumped By:
Dave Tlney---- ___-- ----._. _Mass 1AA95E -- Mass 1AD31
V 7_
tvarrie ehicle license Nr,mt7er
Gafeson Enterprises Inc
Company
7. L {tQf`l Where contents Wert; diSpoS�'(J:
C�LSD
---- - -----
igna ,rr-) o 4 .uler Date -- -
-- —..--
Sfgnalure of fZecelving'Facility (or attach facility receip!)
t5forrn4.doc- 11t12
System Pumping Record F',arje 1 of'I