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HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 85 SULLIVAN STREET 6/6/2025 Own 'f 'Vorth Commonwealth of Massach(.isen Andover � r Cify/Town o� ��N 16 20�5 , - System Pumping Record �5; , � ` 7 Dph has provided this form for use by local ROrVdS of Health. Other forms may be need, bpi»(he I IIoCalrpoard of must Health to dlEtEtrrni�erlhcs(orrr) Ihr.,`, �I�r-5ro�h�n(> (5l�T� fBeforr�� I.I�ir,g this farm, chcckwifh yn,,( y: �urr)ping Record rnt,Isl be submitted to i the local Board of Health or other approving authority within '14 days from the pumping date in accordance witi'T 310 CMR 15,351 _____---_. __.____ _._____.___..._____ _ ______ ___.__ __ HOUSE fron beck sine rf°ar let rig, A, Facility Information E3u11_D_ING front back side rear left riphl Important:Whorl (-)E_C:K ("i Cler (Illing out forrns 1. Systefn LoCc)It fly on the compuler, use, only the I2b Ivey to rnovr>your Ad r ,s5 cursor e do not MA C�lS-Yr use the r©turn VVV-- ---- --- --- --- —.__ .---- — l Cifi /Town _--- ----- __- key. Y ,Tale 7_ip Code. 2. Sys(err) Owner; Name Address(If differ©nl from location) MA Cllty/Town dale _..____.__._ /gyp Code It ---I-e ----------- ------- --- _ Telephone NumP7ar B. Pumping' Record 1. Dale of Purnping Coal t— -` -.______.. Qu�;nhty Purnped. Gallons 3, Component', C] Cesspool(s) [ Sepiic Tank ❑ Tighf Tank [-} Greasq Trap (_ Olher (describe) _ __ ___ _ -------- _ 4. Effluent Tee Filter present? ❑ Yes ( NO If yes, was it cleaned? [] Yes n No 5. Observed condition of component purnped: 6. Systern Pumped By: Dave T l n ey - ---_.------------------_.._-__.__--___---.............___.-- Mass 1 AA 9 5 E ass 1 A D 3 2 Narnr.) VehlCle License Numb r 8afeson En(er rises, Inc ---------- Companyv 7, Galion where contents were disposed �9 D --- -- Slc2nalure r1( }laulef Dale __ __ ... Signature of ftecelvinq Fracility (or attach (acili(y receipt) Dale �--�—��-- 15(ort-M,doc• 11112 �'�W l'Y1 G