HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 33 BEAVER BROOK ROAD 5/14/2025 Commonwealth of Massach(asetts o ' pqh AndOVer
City/Town of
fi System Pumping Record SAY 2025
Form 4
DEP has m
nformatiofnrnv sed this fo(rn t be substG nti�alltyslhE sarne local a>clhat provided here, Beffore Using 1� n),q C"M Mont, f her; f rm r � YOU(
local Board of Health to determine the farm they use. The, System Pumping Record must be submitted to
the local Berard of Health 0r other approving aulhorily within 14 days iron) the pumping date in
accordance with 310 CMR 15,351 _._._
HOUSE f r o n aC ode rear left rid ti.
A. Facility information BUILDIt1G: front back side rear left nt!,ht
Important: When L7[:f:K: Und er
(Ming out forms 1. System LocaltiOn.
nn IN,cornputef,
use only the tab
key to move your llrldr ss
cursor-do not MA
the return —= J �'` ._-.._ ....___._ ... ....-.._.__. ___ C
Cit /town ----_._____------
use .
kc.y. Y Siate 7_ip
2. System Owner:
rerun
Addre,� s(If different from location)
MR
CltylTown Seale Zip Code
felephooe Number
B. Pumping Record
1. Date of Pumping _ _.._ ._.... 2 Quanlit
Date y F�UMnd
p _-_--__.-.__.._...............
C3allans
3. Component: ❑ Cesspool(s) J Septic 'Bank ❑ 'right Tank Grease Trap
14-
❑ Other (describe) -. . _.
4. Effluent Tee Filter present? (..] `rIes -...1 NC) If yes, was it c,Ieanec!? { _] Ynr; (_J No
5, Observed condition of cor-riponent purnpec
6. System PQn-iped By,
Dave T l n e�} ...._ M a Mass 1 A D 31 Z
hJerr�r� Ve Icle l.ir,e �, ur'nber
Bakeson �nfer�ris�s,_Inr_
Cornpany
7, Location where contents vvere disposuJ
9�
5lgnalure of Hauler Lale _..
__.___�._.__ _-_ -.-_-- _
Signature of Receiving Facility (or attach facility receip!) Date
t5 ryrrn4.d0c- 1�1I12 `~ysierTr Pumping pecsrrd � f�apra 1 rr(r