HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 41 BEAVER BROOK ROAD 4/3/2025 Commonwealth of Massachusetts Town of Nollh Andover
City/Town of
APR 14 2025
S System Pumping Record
❑f Farm 4
Healith, Department
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 CIVR 15.351
HOUSE: front back side rear le right,
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling Out forms 1. System Location:
on the computer, t1l
use only the tab -7
------
key to move your Addrelq�
cursor-do not
use the return M A c!) I
key City/Town State Zip Code
2. System Owner:
sG�t ram❑ I G � ��"`,>� �.
Name
-Address (FdT Fferent from location)
MA
CItyfTown State__..___
taif,, Zip Code
i-)o-ne Nu
mber ber-- --
Telep
B. Pumping Record
1, Date of Pumping 2Date , Quantity Pumped,
3, Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
E] Other (describe): . .... ....... ------
4, Effluent Tee Filter present? Yes 1/1 No If yes, was it cleaned? ❑ Yes ❑ No
5, Observed condition of component pun')ped,
6, System Pumped By. -,..,,�fµ.,�,�M -—------
Dave Mass 1AA95�' Mass 'lAD31Z
Name Vehicle License
eateson
Enterprises,
E n t�rpise , 6nc
----"-y'------ I—-------60mpan
7, tion where contents were disposed:
'c"
GLSD
Signature of Hauler Date
Signature of Receiving Facility (or attach facility receipt) Date
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