HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 326 CANDLESTICK ROAD 6/18/2026 Commonwealth of Massachusetts Town of ®��� ndover
City/Town of
wSystem Pumping ecord JUL _ 2026
Form 4
Health
DEP has provided this form for use by local Boards of Health. Other forms may b App, aMnt
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, �_-_— _..__.._.
_ HOUSE: front ack side re�r �le� right
A. Facility Information BUILDING: nt back side rear left right
Important:when DECK: under
filling out forms 1. System Location: .
on the computer,
use only the tab . _. _ 1117
key to move your Address
cursor-do not (" MA
usethe return .__- .._...._.______ __ _____._`__......__..___.�_..__ _�.__..__
key. Cityrrown State ___ Zip Code
2. System Owner
Si�y IDS CfLkC('
..
Address(if different from location)
MA
City(Town State yy p e
Telephone Number .
B. Pumping Record
1. Date of Pumping 2. Quantity Gallons
3. Component: ❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Grease Trap
[� Other(describe):
4. Effluent Tee Filter present? D Yes a If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
System Pumped By:
Dave T i n eY_._.___._. _______._.._....__.____._._..__.__.._....._._......._._._.__. Mass 1 AA95 E ✓ Mass 1 A D 31 Z r
Name Vehicle License tmber r"
Bateson er rises, Inc.
Company
fi. Location he nten diseased:
GLSD ...
nalure of Hauler Date
_.___.._..____-_._. .-_ ___.._.-.____..__.__.....__...._.__.__-_.__._._..
Signature of Receiving"Facility(or attach facility receipt) Date
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