HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 851 FOREST STREET 4/21/2025 Commonwealth of Massachusetts Town of forth Andover
City/Town of LLLaj MAY 12 2025
SYStOm Pumping Record
Form 4 ep� ent
rt
LIED has provided thitform far 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 farm, check with your
local Board of Wealth to determine the farm they use. The System Dumping 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
hnportank When
Sling out forms 1 System Location:
on the computer,
U80 only the tab
r �
key to mode Address -�--
_. _
cumor-do not
use the return ',
key. Cityffow n
StOtQa
2. System Owner:
Name
tale
ip CgKie
'l Nu r
Pumping Record 9
1. Date of Dumping �z i � � �� �
oeke 2. Quantity Dumped:
gallons
3. Component: Cesspool(s) Septic Tank 0 Tight Tank
El Grease Trap
0 Other(describe):
4. Effluent Tee Filter present? El Yes [I No if yes, was it cleaned?
CI Yes Q No
Observed condiWi of COMPOGant punk
6, Sy Dumped B)/:
(i
tdarr
Vehicle nse Number
4
19
G�i any ---�—.�._..---.
7, Locafi where contents were dis
sFkauier
no Funny(or attach fadwy receipt) Doke
a4.do(-11/12
System Pumping Record•Page 1 of 1