HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 408 BOSTON STREET 6/16/2025 To Wn Of
arth�ndover
y ' Commonwealth of Massachusetts JUN K
City/7-own of 2025
z
System PLImping Record
3 Form 4 Depart/hell ,
� DEP has provided this form for use by local 8owcls of i ter It17 Other forms may be usad, bul the
inforn7ation must be substantially the same as that provided r)ere. Be(ore using this (orm, chock with yoi.)r
local Board of Health to determine the (oral Ihey use The System Pumping RecorG',t mt.(s( be sub(TtitteU (o
the local Board of Health or other approving authority within 1/1 days from the pumping date fn
accordance with 310 C M R 15,3 51 --- -------.-------------------._—.._.-----------_.
A. Facility Information — BUI�DIINrG front bark � eh 'rip
hr.side rear
_...__._ k side rear left ri(;t71
Important: Whun nICK ur7C,ier
nuing out forms 1. System Locatio
on(he computer,
Ilse only the lab
ukey to rnovc: your Ar,Jdrnss
culaor -do,(ot tQ 1
0 1(� MA
use the retrn —L=- __ __
yey. city/rown — SlalE. — Zip Code
_ 2. Sys e n Owner:
N a rr1 e
�61111=11AM
Address (If different born location)
MA
Zip Code --- --..
--� _CJ._�/l
r elL'phone (`dumber
B, Pumping Record
11
1, Date of Pumping — '_----._....__-- /'CbGC3
Dale 2 Quantity Pumped. --------___.
Gallons
3. Component: Cl Cesspool(s) Sep(ic tank ❑ l-i h( Tank g ❑ Grease Trap
❑ other (describe):
4. Effluent Tee Filter present? ❑ Yes [ No It yes, was it Cleaned? F---] Yes I_J No
5. Observed condition of component purnpecs:
6. System Pumped By: '°'..........
Dave Tlne Ma"S 1 Mass 1AD31Z
Narno VEhICIr, L i er
Pglwn Fn(erpfises, Inc
Company
7, location whQrc con(cM5 wc(c di5poScd
GLS
lure o Sig1r� f hauler
-----—�— ----.— .-— -------------- -----.- . ...— --
Signalure of Receiving facility (or attach facility receipt), Ogle
I51orP)4.doc' 11112
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