HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 192 LACY STREET 6/30/2025 ` \ Commonwealth of Massach�,isetts Town OfNOM
-�--- Andover
_1 City/Town of
System Pumping Record JUN302025
Farm 4
DEP has provided this form for use by local F300(ds of Health. Other forms may be r.a�c i _,
information must be substonliially the samo, as Br it provided here. Befcore using this form, check wilh yore
local Board of Health to determine the for they use. The System Pumping Record must be submit-ted (o
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
HOUSE front aac side rear left right
A. Facility infOrniation BUit_DINGi front back side rear IeFt right
Important:When DECK: under
filling out forms 1. System Location:
on the compuler, /
use only the tab
key to move your Address
cursor•do not MA
use the return _ _..,__. ___ ___._.._
key. CilytT'awn - -�- Slate 'Lip Code
2. System Owner
-
i,� Name
�eran
_ Address (If different from location)
MA
Cltytown stale Zip Code
Telephone Number
-.____ —_-._ ._-----_. _ ._.-----.- ---...___._
B. Pumping Record c�
1. Date of Pumping Daf t� -----..- - ?. Quantity Pumped: -- --------------.
Gallons
3. Component: Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe): --— — -- -- - __.._..---------- -------------- ------—------- -
4. Effluent Tee Filter present? 0- Ye No If yes, was it cleaned? (_.) Yes [� No
5. Observed condition of component pumped:
Lucy r"-` __--- ----- -------- ------- - -- --
6. System P4amped By:
Dave Tlney____-- --_-- --------____-_.-.__._---__._ ass 1 = Mess 1AD31Z
Namr, >hlrlr t icensr, N rnl7er
gnFeson �nlPr rises, Inr_
cornpany
7. L ation where contents were disposed:
- �2
Signature of Hauler Date ___-....
------------------------ -
Slflnalure of F+ecelving Facility(or attach facility receir>I) Dale -
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