HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 31 BRIDGES LANE 7/10/2025 Tow17 Of rth
Commonwealth of Massachusetts ® Andover
City/ T o w r t of JUL
System Pumping � ����
r y Record
F o rrr-1 4 Health
DEP has provided this fora, for use b locae Boards of Health, Other forms ma k�T.O but the
Y Y
information must be substantially the same �is that provided here. Before taring this form, check wish your
local Board of Health to detern-tine the frarrn they use. The Systern PUMping Record rnust be submitted to
the local Board of Health or other approving authorily within 14 days fror-n -.he pumping date in
accordance with 310 G M R 15,351, —
C.IcL
A. Facility
....Information _.. _..._._ - 8U IL DI,EG front tback� side rear left y
Important: When
0ECK: under
Mling oul forms 1 System L oc;ation
can the;comj:)Wor,
use, only(hici lat>
c
I k I I -
key to move,your cldr)ss -1
uasrsr do not yRK ._..__._.... .......... .-,,_.. _...
use Hit r€;wr Y.. .m _ 5(3la
td
y. Zip C.ode,
S sten) Owner:
._ ._..__
-__..__._ ---
N a r i e
--It --
xn 1
AUdress (If different norr-r loc;allon)
MA
y(1 town Slate 21p Code
relephc nw, Nurnbe+
B. Pumping Record
1 Date of Pumping _° �( - -----._... 2 Quantity Pumped'.
(late oallvns
( (�� ce sspool(s) El tiG Tank
3. Com�oncril, [-I Ticht Tank
,� ❑ Grease 'trap
oll
Other (describe) ---- _ _..---------
4. Effluent 'Tee Filter present? (�._� Yes [ -�, No if yes, was it cleaned? Yes Na
~'
5. Observed condi(ion of component pru�rnperif
l yC 1 v _.
6 Sy .k6-ln PLIrrtped By
D ve f"iriey (Vass 1AA95E sass 1 f (a '1l
hJ ne Vefiicir t..lcense Nurnber
E32 'or nieq)risps, Inc:.
C'ofripany
I. aD/ti 0 r)
Wrtere, r1t3 W e f edIS P0 SE;'d.
GLA
Signature t7( Hauler Date
_._..__.._. .
-__--------
Slgnalure of Rcr„�e vliuf (=rscilily (or atlacYr (e+<,ilily re�rcir.,l) Dale
5(C7rm4 doC '11112 `7ysles(,n llumr)09 Record , Page 1 cif 1