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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 FULLER MEADOW ROAD 7/29/2024 Commonwealth of Massachusetts 10% o ' L Andover City/Town of System Pumping Record Form 4 ent e a, 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 CMR 15.351. HOUSE: ront back side rea pl right A. Facility Information BUILDING: front back side rear right Important:when DECK: under filling out forms 1. System Location: on the computer, e— r ( /I t use only the tab 2c> �u lQ{ �L k CGC., ` C key to move your Address cursor-do not use the return Ai ./^ � C3� tJ�- MA key. CilylTown Slate Zip Code 2. System Owner: Name J mvn Address (if different from location) MA Cityrrown Slate Zip Code 4�9- C-10 Telephone Number B. Pumping Record 1. Date of Pumping 2 � p 9 Date 2• Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed ;onditiiomponent pumped: Gurn�� 6. System Pumped By: Dave Tiney Mass 1 AA95E ss 1 AD31 Name Vehicle t icense Number Bateson Enterprises, Inc. Company 7. ntion where contents were disposed: 2� L nr Signature of Hauler Dale Signature of Receiving Facility(orattach facility receipt) Date t5form4.doc, 11112 System Pumping Record•Page 1 of 1