HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 103 FULLER ROAD 6/23/2025 _
Town of Forth Andover
COMn,iioriwealth of Massac; -i ,setts JU�1 23 2025
! - City/Tcawn �f _______�_
System Pur�� ���ing Record
F a r rr1 4 Health Department
DE P has provided this forr'r1 for use:' by local Boards of l iealth. 0ther farms (nay be used, but the
inlormaliun rrtt..isC be subslaniially the sarne as lha1 provided here. Before using this form, check with yot
local Boa1rt1 of I iealth to determine the; for ri they use, The System Purnping Record must be submitted
the local Board of Health or other approving auihority wiihin 14 days from 'he pumping slate in
accordance. with 310 CMR 15 351 ___----.-___ __.____..._.._ .._ ___ --------._.._ _-----.
HOUSE (rant back side rear left(
A. Facility lnforrTlcatior7 BUILDING; front back side rear left
Important;Wizen
DECK: under
filling out corms 1, Syslern Location
on he rOrnt)WW,
use ofdy the tab
Key to move ycrui la,tadresv
Cursof do not
use I h u r(l u i n
k S' _.___.__... .. __ _.____..........__
;i(yFTo n Shier Zip Code
f'
7. Syst n.1 Owne:r,
Name
Address (it di fe(onl irorn locailon)
MA
....
Cily/Town ti Vale Zip Code
I" Q _-------.___.__._..... _
B. Pumping Record
1. Dade of Pu Aping � ' --..-__.._ , Quantity F t.)mped'.
Cate Gallons
;S. Component (_ r,'1c ssr oGl(s) Se(rtir., Tank (_.3 'right Tank Grease Trap
M Other (describe); --. .__.-- _ _..._ _------------- _ .___.... _.__ ...... .......
4. Ef9�Vuent Tee, PjIlter preseni y (_.....] ��f(2 ) rvlr�) f yes, was it cieaned7 (J Yes (�� No
5. Obseive,d condition of cornponerll purnped
6, `ysleein Pt.jrnpe'd By.
Dave I in y_ Mass 1 AAg5f Mas 1 AfL i l l
hlanbrt - vc.hicie License Kjumber
B fleson E_f ferprl ses, Ific
7 Location where Contents were disposed
Cal_�t:
/, _
--
'rigrlattue of Re<,elving F<7cllity (of attach Grc;ilik'y rea,ipt) Dale - ---- -------
lbrorn-i4 eioc, 11(I2 ;ysierrl Purnping Record Pagce 1 01