HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 136 ROCKY BROOK ROAD 7/29/2024 Commonwealth of Massachusetts
Andover
City/Town of JUL 2 92024
System Pumping Record
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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: fron back side rear left right
A. FacilityInformation BUILDING: tr'tfit back side rear right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, � ��
use only the lab I �O
key to move your Address
cursor-do note�QLJ�� MA /
use the return Cil !town
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2. S to Owner;
°A C
Name
relu7r
Address (if different from location)
MA
Clly/Town State Zip Code
GO P, G8-y
Telephone Number
B. Pumping Record
1. Date of Pumping DateZr 2 2• Quantity Pumped: Gallons j
3. Component: ❑ Cesspool(s) �] Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe).
4. Effluent Tee Filter present? ❑ Yes I A No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Q2
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD31Z
Name Vehicle License Nu bet
Bateson Enterprises, Inc.
Company
7. on where contents were disposed:
rGLSD
Signature of Hauler Da
Signature of Receiving Facility(orattach facility receipt) Date
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