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HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 136 ROCKY BROOK ROAD 5/30/2025 Commonwealth of Massachusetts Andover C'ty[Town of �.,° Syst r-n Vamping Record =y ;r Form 4 DEP has provided this form to( usp by local Roeirdss of I ir,,a r. <:)fr7F_�r (ori��s rn��y��u�r r. �Ati � information must be subsiantially ltre same ,is piovid nj bore f3elorc; using Ihi, forrrt, check with your local Board of Health to determine the form Bhey use, t he System Pumping Record must hr�sr,OMitted to the local Board of Health or other approving authority within .1r1 days from the pumping dale in accordance with 310 CMR 15,351 H0USE: from back side rear IFlf hht A. Faclll,ty Inforr7-Cation 3UILDIM rJ(.le rear left r;gr,t Important;Whan DECK_ udder (Illing out(orrns System Location on the compular ._ rests only Ihn iat) key to rnovr;your ArJt9rc�s _- cursor -do not �Ql// use the return -- ---- MA key. Y dale - - -- -- Zip Code 2.,,, Owner. Name --- nran Ad6ress(If dilferonl from location) MA Cade Telephone N u rn by e f __._.._-_.___.___--._-----_--- B, Purnping Record 1. Date of Pumping oa ` --- - - 2. Quantity Pumped Lallans 3. Component: ❑ Cesspool(s) Se=piic TanR ❑ Tight Tank [] Grease Trap E) Other (describe): -- - ___-- 4. Effluent Tee Filter present? �] Yes _--� I�r� I( yes, was it cleaned? D Yes F (ju 5. Observed co/nddi)(io of corrlponent )urnped: 6 System Plimpe5d By. Dave Tine Mass 'IAA95E CMass 1AD31 am© Vehicle License Number PAnn En(ernrisos, Inc. cornpny 7. La'- on where conlcnts were disposed. GLSD Signature of Hauler tale -------.---e-___Recelv4nqe—r(-_-ci_A _ Sl�nalure of Cy (or af1ach facility rr.t.ripl) natr _______ 510rra4.dOc 11I12 �;vslnrn r>........n„