HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 165 VEST WAY 7/8/2026 T
Commonwealth of Massachusetts own of Nz ki Andover
City/Town of
System Pumping Record JUL 15 2026
Form 4
Healtil
DEP has provided this form for use by local Boards of Health. Other forms may PAPAftent
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. 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. 7
HOUSE: Pro In back side rear le4�rig bt
ro
A. Facility Information BUILDING: ront back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not Aq) MA
use the return
key. City[Town State Zip Code
�❑ 2. System Owner:
Name
Address(if different from location)
MA
City/Town State 44 Code
LL
0't
A5
Telephone Number
B. Pumping Record 9-`--- 2. Quantity Pumped:
1. Date of Pumping -bate lions
3. Component: ❑ Cesspool(s) L;-Se° tic Tank 7 Tight Tank ❑ Grease Trap
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes L-�o If yes, was it cleaned? ❑ Yes F No
5. Observed condition of component pumped:
�
6. Sy g Py ed By:m W
—
Mass 1A95E Mas'&4e 1AD31Z
N me
Vehicle License Number
B"te$on Enterprises, Inc.
Company."
7. n where contents were disposed:
LSD
-Signature of Hauler —Date
Signature of Receiving,Facility(or attachfacility receipt) Date
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