HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 29 WHITE BIRCH LANE 8/31/2026 Commonwealth of Massachusetts Town of Not Andover
City/Town of S P 14 2026
System Pumping Record
Form 4
❑� '{ alto 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 san-,e 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 GMR 15.351. -----
___.____� �_.______..__ HOUSE: front �acide rear l f ,,, ight
A. Facility Information BUILDING: front c7 side rear left right
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filling o�k formsbUter, 1• Sys-tern LO tIOIV -
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key. City/Town State Zip Code
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'—'-"- Address (if diffcrer7t from location)
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Ciky/Town State q ip Code
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Telephone Number
k . Pumping Record
1. Date of Pumping Date
._.__.._.__.__...._......___.___-.__. 2. Quantity pumped:
Gallons____._.__.____ _.___...
3. Component: ❑ Cesspool(s) ----Septic Tank ❑ Tight Tank g ❑ Grease I"rap
❑ Other (describe): ..___...____
4, Effluent Tee Filter present? ❑ Yes tVo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of moripnent purn e�,'
& System Ptfmped By:
Dave Tiney _ Mass '1AA95EL,,Mass
Ba C7r1 Enterprises,In_c_
Company
7. Location where c ntents were 4 sposed:
G LS
Signature; of Hauler Date
_.. __�_--, ------ _.._.__....... ----
Signature of Receivli7g Facility(or affect) facility receipt) rate
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