HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 284 SUMMER STREET 10/7/2025 Commonwealth of Massachusetts pin ° �a `h
x ' City/Town of Andover
y System Pumping Record
W Y p OCT Form 4 2025
❑v 4--:J.e
DEP has provided this form for use by local Boards of Health. Ot4lee ftn e used, but the
information must be substantially the same as that provided here. Before uslr with your
local Board of Health to determine the form they use. The System Pumping Record must bmitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
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A. Facility Information BUILDING: r D NG: orM back side rear le.__ right
left right
DECK: under
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filling out forms 1. Stem ya
on the computer,
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key to move your Address
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City/Town State Zip Code
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2, Owner: 4,
--.-.___..____..___
Address(ff different from location)
MA
City(Town State / Lrp Code
Telephone Number
B. Pumping Record
1. Date of Pumping -- ---______ 2. Quantity Pumped:
Gate Gallons
3, Component: (❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --- ______-________
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes Q No
5. Observed conditio of component pumped:
6. Syst mped By: .,.
D e TineMass 1AA95E Mass 1A 31Z
Na e ti Vehicle License Numb
Bate n enterprises, Inc
----
Cornpany
7. Lac tio,n where contents were disposed:r,,....--
G S ❑
Signature of Hauler Date
__._______ .___-_._____- _..-._. ___.. .. __._ ....-_- _..___—.
Signature of Receiving�1=agility(or attach facility receipt) Date
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