HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 74 COLONIAL AVENUE 4/29/2024 Commonwealth of Massachusetts Town of Wh Andover
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Health Department
DE.P 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 CMR 15.351.
A. Facility information _— —_ —.
Le ght fr t of house,. Left/Right rear-of house, Left/Right side of house, Under [
Important:When
filling out forms 1. S� stem Lo ati n: Left de of building, Left/Right front of building, Left/Right rear of building,
on the computer,
use only the tab _--
key to move your Address �,�i�- /� f�/
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cursor-do not �If MA
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use the return
key. city/Town state Zip Code
2 S tem timer:
Name ___---
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Address(if different from location)
MA
-- - ---- - --- --
City(1-own SEat� 7.io
Telephone Number
B. Pumping Record
=a .
{ 1 Hate of Pumping Date 2. Quantity Pumpe .d Gallons
i
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - - - - - —
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pum ad:
I
6. System Pumped By:
Dave Tine— Mass F5821
1 Name Vehicle License pumber
Bateson Enterprises, Inc.
Company
7. Loc * n whe contents were disposed:
LSD
signature of Hauler Date _
SiUnal.uie pf R(._cP1ving Fai;ility(Oi attach fai:ility iliii
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