HomeMy WebLinkAboutSeptic Pumping Slip - 11-27-2024 - Septic Pumping Slip - 165 CARLTON LANE 11/27/2024 Commonwealth of Massachusetts
City/Town of N, Town of No�h System Pumping R- ecord Andover
loll rm 4 JAN ' 12025
DEP has provided thieform for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. MAndisorrn, check with your
f I ocal Board of Health to detennine the form they use. The System
RARO"f*mitted to
the local Board of Health or other approving authority within -14 days from the Pumping date in
accordance with 310 CIVIR 15351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Ad-dress
cursor-do not
use the return
key. cilyfrown statP
2. System Owner:
Name
1iW1i_MsW(if dIfferent�from location)
Tkir-Fo—wn
State Zip Code
B. Pumping Record
1. Date of Pumping --illoak,
Date 2. Quantity Pumpe& ------
& Component: Gallons
0 CessP00I(s) Septic Tank El Tight Tank F-1 Grease Trap
n Other(describe):
4, Effluent Tee Filter present? 11 Yes [1 Na If yes, was it cleaned? Cl Yes No
5. Observed condition of component pumped:
& System Pumped By:
Name "Vehicle License Number
'company
T Loc on where contents were disposed:
Dole
6iie
Mformol,doc-11112
System Pumping Record-Page'i of 1