HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 427 WINTER STREET 4/8/2025 TO" of
Commonwealth of Massachusetts orb AndOver
H City/Town ofAPR
n System Pumping Record 2025
r Farr-r7 4
DEP has provided this forn-) for use by local Boards of Health. Other forms may be Used,
information must be substantially the same as that provided here. Before using [his form, check with yot.,r
focal Board of Health to determine the form they use. The Systern Purnping Record must be submitted to
the local Board of Health or other approving authority within 14 days from -he pumping date in
accordance with 310 C M R 15 351,
HOUSE, front back side rear left )rif;I
A. Facility Information BUILDING: front hack side rear left rift
Important: when DECK: under
tilling out forms 1 Sy91(yrFown
stern,Loc. tion:
on the computers
use only the tab
key to move your
cursor-do not MA
1 use the return _-_... _.-----__ ...__ _.._. _------- —_.----._..____ _... _.-__,.
key Slate Zip Code
v 2. System Owner:
lYIIYl1 f�
Address (if C ifferen! from EocatIon)
MA
Y dale Zip Code
_..._.._.._....
'Telephone Number
B. Pumping Record
_
e
1. Date of P u rn p i n g Ytte ------'„-----._____.---... 2. Quantity Pumped _.._.._. —_—
Gallons
i
3 Component: Cesspool(s) Septic lank (❑ Tight Tank ❑ Grease Trap
f -
0 Other (describe) -._._ -----------__.
4. Effluent Tee Filter present? Cj Yes a If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of cornponenl pumped
i
6. Systen-i Pumped By
Dave Tlney Mass 1AA95E Mass 1AD31Z
Name Vehicle license Nur•nber
i Baleson Enterprises, Inc.
Company
7. Location where contents were disposed
GLSD
Signature of t1auler Date
)
Signelure of Receiving F'acilily(or aflsrch fsr„ici(y re;ceipl) f7a1F,
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