HomeMy WebLinkAboutSeptic Pumping Slip - 10/3/2024 - Septic Pumping Slip - 72 PHEASANT BROOK ROAD 10/3/2024 Commonwealth of Massachusetts o o orb
Andover
w City/Town of
n System Pumping Record FEB ., 42025 Form 4
DEP has provided this form for use by local Boards of Health. Other forms a but the
information must be substantially the same as that provided here. Before using thi o , ith your
local Board of Health to determine the form they use.The System Pumping Record must be su mitted 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
Important:when
filling out farms 1. System Location:
on the computer, }
use only the tab
key to move your Address
cursor-do not //„„ v —
use the return �.
key. City/Town State Zip Code
2. System Owner
e
Name
Address(if different from location)
----.._ .. .— -.._...- -- - .-............ ---. - ----
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -------------------- --.. .... 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — --._......_..----.........-____ --............._....._.._.._.._.._.--- - -- — --.__......
4. Effluent Tee Filter present?Xyes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditI n of component pumped:
P
6. System Pumped By. .
-d q1-7
rc +
Name r Vehicle License Number
Camp
. ocation w o tents were disposed:
-- --------_- ---
Signatu e` auier Date
signature of Recei " acility(or attach facility receipt) Date
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