HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 284 BRADFORD STREET 3/31/2025 commonwealth of Massachusetts Town of IVOrthAndover
- City/Town of
System Pumping Record APB 025
Form 4
HOW
DEP has provided this form for use by local Boards of Health, Other r _ Phis ut the
information must be substantially the same as that provided here. Bpfore using for , check with your
t
local Board of Health to determine the form They use. The System Purnping Record must be submitted to
the local Board of Health or other approving authority within 14 days from -,he purnping date in
accordance with 310 (WR 15 3151 _
HOUSE: front back sid rear eft rigI
A. Facility information BUILDING: front back side rear left rigr
Important:When DECK: under
filling out forms I System L ocatlon
on the conopuler, &�dres—s
ruse only this tab � ___..key to move your Cursor-do not .�i MA___..._�_
Ay 5lafe Zip Code
use the return _ own
key.
2r Systern Owner
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4
Address (if ditiero of from location)
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Cily/Town Sla -� / Zlp Code- =-- '
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Telephone Num er
B. Pumping Record
1. Date of Puriping _.___ ___--------... 2. Quantity Pumped ----- �___
(Talc Gallons
3. Component: ❑ Cesspool(s) Septic `rank ❑ Tight Tank ❑ Grease Trap
r
I —
(_� Other (describe)� ._....._._
4. Effluent Tee Filter present? (. J Yes tJo � f yes, was it cleaned ❑ Yes ❑ No
5. Observed condition of component pun)ped
6. System Pumped By.
(:Save iiney Mass 1AA95E Mass 1AD31Z
— —
Namr, vehicPc I�Icense Number
Bafeson Enterprises, Inc.
i, company
%. Location where contents were disposed,
GI-SD
I
si nature of HaulDate
g (7 a t ray
_..... - .._. --_._ .
Siynaturc of rieceiv{(sg F aciVity (or (ar,ility recelpl) ['laic
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