HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 162 BRADFORD STREET 4/24/2025 Town of'VOrM
Commonwealth of Massachusetts Andover
�- City/Town of
APR 28 2025
System Pumping Record
7
F o r r-n 4 Health- >' epee"$ *
DEP has provided this form for use by local f.3craras of Health Other forms may be used, but the
information rnust be substantially the sarne as trint provide
.d here. E3eforc, using this form, check wi(hi your
local Board of Health to determine the foffn ihr;y use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the purnping elate if)
accordance with 310 (;MR 15.35 r
_ ___-
-_--_ HOUSE: eon ba side re e .
riphT A. Facility information BUILDING: front hack side rear left n�hl
Important; WI)on DECK: i_ n d e r
filling out forms 1. System Locatior'l:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return —__)_r __ ? �__...____. _- ----- ____._.__..__ M _------- 4
key, City/Town ale; Zip Code
--- 2 System Owner:
10 red
Name
Address(if different frorn loca(lon)
MA
Clty(Town slale y Lip Coda
Telephone Number
_._.._ _ __.__._,__--_..__._---._.__._
B. Pumping Record
c�
1. Date of Pumping / _ ._._.._____-._ 2 Quantity Pumped
Gat; Gallons
3. Component; ❑ CesspooV(s) [ Septic Tank ❑ 'Tight Tank ❑ Grease Trap
Q Other (describe). _ _.
Q, Effluent Tee Filter present? (
j Yes No If yes, was it cleaned? �_] Yes ❑ No
5. Observed condition of corriponent pun,)peci:
C, System P4lmped By;
Dave TIneY Mass 'IAAq-5E Mass IAD31Z
Namr3 Vehicle License Num er
eafew Enter rises, Inc.
Company
7, iorl where contents were disposed:
(aI.SU
SicgnalufP of Hauler ()btlr^
Signature of Receivingr'aclilty(or attach facility receipl) Dale --
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