HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 70 CANDLESTICK ROAD 6/16/2025 7-^mn �� N��� Andover[,[}����[�[]������\t�� [)f K8ass��Ch�3E�ttS
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System Pumping Record
FD[r04
Health Department
DEP has provided ihiy form /o/ use by local Boards of Health. Other /o/rns may be used, but the
information must be substantially the uame as (hoi provided here. 8e/ore using this fo/ , check will) yov'
local Board of Health (o determine ihe <orm they use The Sye\enn Pumping Record mus| UesubmNeV to
the local Board of Health u/ other approving authority within 14 days from (he pomping date in
accordance with 318CMR 15,351 ------- -
HOH�E front back rear |e� *���`
— -------- ��� \��
A. F8CU'f« information BU|t-D|wG front hack side /ea, \eh '/Km
|mportunt�When UE('x: ooger
(filing out mnw 1 System Location
oo the computer,
Use Only the tab
key m move you( Address -- ' - �� -------
om^o' do not
use mo 'mvm ___ Mx
ko', °'r'~~^ uo'o uv Code
2. System Owner
wumo ���--' ----
L-M
xuum,^ (If different vomlocation) ��� ����-----�'-----------------------
MA -------
Cltyffowo
Zip Code
re/epxooewvmuu/ ���--------
B. ��UO1[>in�� Record ���- �---------------------------
1, Date ofPumping ------- 2 Uu2n(ityPumped,
Date
I Component: Ceanpoo|<y> Septic Tank Tight Tank Grease Trap
Fl D(her (describe),
4� Effluent Tee Filter present? [] Yey No If waai\ cleaned? [] Yes [� mo
5. Observed condition of component pumped.
O. System Pumped By:
OmveT|neMass 1/�A95E Mass T�AD3 IZ
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wom* vewc� uuon,o w","ue, -__~
kemn
Company
7, LoQ-a(ion Micrc
Ignal ro)aulef
Signature of ReceIvIng'Facility, (or attach facility (eceipt) Date
8onn4,dom' 11A7 SyuIempvmp/ogHrow px ^ I o/ 1