HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 547 WINTER STREET 10/16/2025 Orth
Commonwealth of Massa awn Andover
(p City/Town of OCT
System Pumping Record 25
Farm 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but they
t
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 Pumping 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. ._.
HOUSC: fro ack side rear I ft ri ht
A. Facility Information BUILDING;. back side rear left ri ht
Important:When BECK: under
y Location:
fillingout forms 1. System
on the computer, ,7 (Xxj
�
use only the tab _.key to move your Address
cursor-do notMuse the return _ St ____ _
Zip Code
key. y - ____._.__.._____.—___ . ,..
W/L;12
2. System Owner:
-�
( Name
rnrrrn `�)
Address(if different from location)
MA
Cit (Town State ip Code
Telephone Nu bar mb
B. Pumping Record �
�_..
1. Date of Pumping aaie � __.__-_._. 2. Quantity Pumped: -�/auor s
3. Component: ❑ Cesspool(s) eptie Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -------------- —
Effluent Tee Filter present? ❑ Yes LL No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compone t pumpe
6. ysteh Pumped By:
Dave Tln - --� _.._.._..___.._._.._.....___..__._.._...__..... _._.__. Mass 1 AA95E ss 1 AD31Z
Name Vehicle License Number
te Enterprises, Inc.
Company
7, anon wh come s diseased;
LSD
Signa ure of hltaul Date - y _-.--
________ .
Signature of Receiving Facility(or attach facility receipt) Gate
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