HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 780 FOREST STREET 7/9/2026 of
Commonwealth of Massachusetts Town ph Andover
City/Town of
JUL 15 2026
System Pumping Record
Form 4
Health Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 CIVIR 15.351.
HOUSE: front baccsiD rea right
e
BUILDING: front back side rear Facility Information r e right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab b 'r -:5 -- --
df
key to move your Ad ress, I
cursor-do not iki A MA
use the return City own State Zip Code
key.
T--(� 2. System Owner:
t
Nat e
Address(if different from location)
MA
City/Town State Zip Code
37
-Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: 7 Cesspool(s) L-JAeptic Tank ❑ Tight Tank 7 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? CY-es�E] No If yes, was it cleaned? Z;,Ifle"s ❑ No
5. Observed condition of compone t pyrnped'.
6. S Pumped By:
y
ave Tine Mass 1AA95E ass 1AD31Z
Name Cmm—ee 'Vehicle License Number
te
at son Enterprises, inc.—d—om-p-a—ny *
7. Location wheTontents were disposed:
G�L,(
Signature of Hauler LL- Date
-Signature of Receiving-Facility(or attach facility-re`c—eipt) Date
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