HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 268 REA STREET 6/11/2026 Commonwealth of Massachusetts Yawn Of IVOAth AndoVer
City/Town of
System Pumping Record JUN 15 2026
Form 4
Hea/th Qt
DEP has provided this form for use by local Boards of Health. Other forms may be 4046 41* A
information must be substantially the same as that provided here. Before using this form, check w'it your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
HOUSE: fron<b!�k ide rear left right
A. Facility Information BUILDING: front back side rear left riilffflt
Important:When DECK: under
filling out forms 1. System Lo' ion:
on the computer, �eao
use only the tab `aS
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner:
------------------------
Name
Address(if different from location)
MA
City/Town St to Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: Gallons
�ptic Tank [-I Tight Tank F-1 Grease Trap
3. Component: ❑ Cesspool(s) d:j--15'e
❑ Other(describe):
4. Effluent Tee Filter present? Yes No if yes, was it cleaned? 'E5Yes M No
5. Observed condition of component pumped:
6. Sy�steP-Aymped By:
e Ti
e Ti Mass 1AA95E Mass 1AD31Z
42-ma-, Vehicle License mber
Bateson Enterprises, Inc.
Company
7.7tion re n nts were disposed:
I
GLSD
Signature of HaDler --
of Receiving Facility-(or—attach facility-'receipt)---.-
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