HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 150 JOHNNY CAKE STREET 8/18/2025 \ .. Commonwealth of Massach(. self� Town Of o�;�Andover
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DEP has providr.scd tt.w; forrr) for use by local f3otan:ds c,al tie;�allla. C.; Mer farms n ay 1 >'C "hGpnt
inforrnation rrrust be <>t.rbstantially the, sarne ar, lhnt piovirlrtcf he��rr- i3rsf(--)ro L,sing Ihis:, form, c17erk vwith ycrr.�r
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lheallocalaBoardfof�lV�e ffi ore�otl�aer�atpprovuat�ll,.Wthork wlttt'llnr 14 days the ecr�)rr1 n�dt.l;t le ^�,utarnitt�°e,1 is
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y y �aurraping c1 ate in
accordance with 3'10 CMR 15.351 _.._.._ _.... . ........
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2. t rn Owne>r
Fir)dross (If(Jltferertl from lacalion)
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B, Pumping Record
'1, Date of Pumping .... ?_. Cu:antity F'urnf F=c:f - .-.. .._..._. _..
0 ale, Gallons
3. Componen(: (❑ cesspool(s) (- eplic Tank � 7 Tight Tank ❑ Groase Trap)
Other (ctescribe):
,I. Effluent Tee filter present?�(� Y 1s ( ] No Vf yes, was it cleaned? Yes es No
5. Observe;cf t ondi(i an of cornp r) nt purnped
F�, Cav
rr'a f'l,lrr"ipe)c;l By
FInr - -- --.. M�a s I A 5 Mass 1 AD317
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Vr.h1cle. License Hurnbef
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Comp,viy
7. Localiurl_wftcrc rr:onterrts vvere,.�d po e is
Signalurr� of hraulcr(
gn�ilurr. o ece vinr -�aci ity (or atlact7 <acmiy r�aceipl) Uale
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