HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 BRUIN HILL ROAD 4/10/2025 .:� Commonwealth of Massachusetts
Andover
City/Town of APR 22 2025
System Pumping Record _
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DEP has provided this farm for use by local Boards of Health. Other farms 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 CMR 15.351,
A. Facility Information
Important:When
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on the computer,
filling out forms 1. System oca o
use only the tab 11
key to move your Add _. t ..1
Address
cursor-do not
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key. ity/Town
use the return State Zip Code
VQ 2. System Owner:
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Name
6 ...........
.........._............ _-- .--__.. __._ __ _-_— _.. ...__._.._ _ . _ _
Address(if different from location)
City/Town state Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �. .. -- Z. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - _
4. Effluent Tee Filter present? ❑ Yes El No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped B
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Vehicle License Number
Company
7. Location where contents were disposed:
C
- ------- --
Sign�tut"e of ul w,„
Date
Si nature of ...eo!9 ,ng.___Fa _ ._.._......_ .
g aicility(or attach facility receipt) Date
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