HomeMy WebLinkAboutSeptic Pumping Slilp - 9-12-2024 - Septic Pumping Slip - 1424 SALEM STREET 9/12/2024 Commonwealt of a Musetts Town cart Andover
City/Town of
w System Pumping Record FEB 4 2o25
- Farm 4
}' DEP has provided this farm for use by local Boards of Health. is but the
'information must be substantially the same as that provided here. Before usin45L ck 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
Important:when
filling out farms 1 System Location:
on the computer,
use only the tab 4� .!4
--_ _. .._. _ ..
key to move your Address
cursor-do not
�' /
use the return _._ _.. ---° .____.- ".....__.._ ___._ _.. _.. -_._.--_ -----
key rty own State Zip Code
2 System Owner:
11111'.� .. -- _ �cal_
----------
Name
Address(if different from location)
_..._- ._.._.-........
City/Town State Zip Code
Telephone Number
B. Pumping Record zq
1. Date of Pumping 9// - --- 2. Quantity Pumped: ---
Date 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? F� Yes ❑ No
5. Observed con Rion of component pumped:
6. System Pumped By:
( ' -- -------— l /
me Vehicle License Number
Company t
7. Location wwhere tents were disposed:
—-- - _ ......-, .. . _, .__.._ _,
Signature of lei Date_
Si natureof Fte ruin.g_..
g w ' Facility(or,attach"facility receipt) Date
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