HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 58 OAKES DRIVE 10/16/2025 Town of NOM Andover
Commonwealth of Massachusetts
City/Town of
v � M ' OCT 16 2025
System Pumping Record
4 ,e Farm 4a n
- partMent
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this farm, 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. fron .. Ide r_a right_. .
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
on the computer, ati0n: _.
ue only tab 1. System .
filling Y"
y
key to move your Ad P-
cursor-do not �y/ MA
use the return — -- _. d---.-- � ---- ----
key.
City/Town State Zip Code _...__._.
2. Sy em Owner,
ED—
-Name
IMP
Address(if different from location)
MA
C(ty/1'own State lip Qode
Telephone Number
B. Pumping Record
1. Date of Pumping -ati "_ — - — --- 2. Quantity Pumped: IIons
3. Component: ❑ Cesspool(s) , a--!�eptic Tank ❑ Tight Tank ❑ Grease Trap
[�] Other (describe):
4. Effluent Tee Filter present? es ❑ Na If yes, was it cleaned? ❑,..Yes ❑ Na
5. Observed condition of component pumped:
6. System Pumped By:
_Davey _ _ Mass 1AA95E ass 1 31Z
Name - Vehicle License Number
ateson Enterprises, Inc
Company
7. Location where contents were disposed:
Signature aftauler Date �—
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11/12 System Pumping Record •Page 1 of 1