HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 155 CHRISTIAN WAY 7/9/2026 Commonwealth of Massachusetts Town of Nmt)Andover
City/Town of
System Pumping Record JUL 15 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other for
rllot��noqqour
information must be substantially the same as that provided here. Before using
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.
rig
t
HOUSE: front I back side rear
< e f tCr I—gi
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab 13 —-----
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. Syste- -wner:
/Z Name
own
Ii 21=2
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record -7 A-9 -- 2. Quantity Pumped:
1, Date of Pumping Date Gallons
3. Component: Cesspool(s) Er,�e 'tic Tank 0 Tight Tank D Grease Trap
0 Other(describe):
4. Effluent Tee Filter present? F-1 Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
ole,
6. Sy em Pumped By:
ve Tine Mass 1AA95E Ids D 3 1 Z
N e -Vehicle License Nu
eso,in Enterprises, Inc.
Company
7 Location wh e contents were
GLSD Ile,
"Signature of Hauler Date
7 liji(oratfa faC�jt�reCj
Signature of Rec,�iTlnjY-0, Date
t5form4.doc- 11112 System Pumping Record-Page 1 of 1