HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1230 SALEM STREET 5/6/2025 rown Of
Commonweakh of Massachusetts hA'do'er
x� City/Town of No.AndoverN
System Pumping Record20z
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4 Form
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DEP has provided this form for use by local Boards of Health. Other forms may be use ,
information must be s0.,bstantially the same as that provided here. Before using this form, check
ew'tits 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 ( MR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 471
use only the tab --
key to move your Address
cursor-do not
use the return _... .
key.
City/Town State Zip Code
ran
2. System Owner:
Name
ensn
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Num ber
B. Pumping Record
c
1. Date of Pumping -`' - G
2. Quantity Pumpe --- � ,
Doke d: all ns
3. Component: ] Cesspoal(s) ,�peptic Tank "right Tank ] Grease Trap
j Other(describe): _ ........ . .....__-.._ ... _------------- --------- --
.e
4. Effluent Tee Filter present? es j No If yes, was it cleaned? 'Yes No
5. Observed condition of component pumped .
6. System P peJdB
Name Vehicle License Number
Stewart s Septic 58 So Kimball St Bradfard,MA
.............. .
Company
7. Location where contents were disposed:
20 So.Mil ac9fard -._-----------
05 /2 6?�)
Date
Signature of Receiving Facility(or attach facility receipt) Date
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