HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 506 SALEM STREET 9/19/2025 Cflvorth
Commonwealth of Massachusetts Andover
City/Town of P 19 205
System Pumping Record
Farm 4
C oepcirttr
DEP has provided this form for use by local Boards of Health. Other forms may be u , t the
Information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Purnping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15,351
_.___-_
_ I-ICOUSC. fron lock side re f right
A. Facility Information SUIt_DING: 1`Fj t back side rear left: rigi-it
Important:When DECK: under
f1ting out foron the room Liter, y C7n
ms System Location,
p
use only the tab
key to move your Al s
cursor-do not
use the return _.-. M
key.
Cifyrl-own State Zip Code
2. Syste ner.
y - _--_--__
----------- -------
Address (if different from location)
MA
Cityrfown - Stag,
ele __ Gip Codr
T >2Z)>rr
B. Pumping Record
1, Date of Pumping __-- . - 2 Ouantity Pumped.
3. Component: [ j Cesspool(s) [ Septic 'tank ❑ Tight Tank Grease Trap
❑ Other (describe) __ .--.___._ _.__.__ _._____. _._..._
A. Effluent Tee Filter present? Yes (_.. o If yes, was it cleaned? [l Yes (_� No
5. Observed condition of corrii anent pun-p,ed
6. Srte�son
a Pumped By:
lne Mass 1AA95E MLp
31Z
V hlGfe l.ir„i,nho Nurrit,7er
B Enterprises, Inc.
Company
7. oc tion where, contents were disposed:
MD
Signature of auler Date
Signature of RecrelvIng f acuity(or attach facility receipt) Date —
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