HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 163 SUMMER STREET 10/7/2025 �m -
Commonwealth of Massachusetts �-
u = _ C ity/Town ofown of h Andover
= .v System Pumping Record
Farm 4 OCT 7 2025
DEP has provided this form for use by local Boards of Health. arm may be used, but the
information must be substantially the same as that provided h r . e heck with your
local Board of Health to determine the form they use. The System Pumping Record must e 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, --___.
HOUSE: front 0" side ea- left Ipht
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1• System Location
on the computer,
use only the tabs r
key to move your Address
cursor-do note (�c
use the return
key, CityfTown State Zip Code
2. System Owne
Nar"ne
1��
'Ell
V
Address(if different from iocation)
MA
CityfTown State !i
Telephone Number
B. Pumping Record
1. Date of Pumping pate _ __.______-._____-- 2. Quantity Pumped: 1�0 s — _-�---
3. Component: ❑ Cesspool(s) �Z"Septic"rank ❑ Tight Tank ❑ Grease Trap
E] Other (describe); ____..______ _._____.__.__--__ ___._._-....___
4. Effluent Tee Filter present? ❑ Yes ZNO If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component ppuu�mpe
i
6. S ste limped By:
D veTir7.__y_...._ _ .__ Mass 1AA95EMa 1 DD31Z
Na e Vehicle t_icense Number
Bateson
Company
7. Lo ati e c "ents were disposed:
GL
Si9r7ature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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