HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 31 OXBOW CIRCLE 9/19/2025 Commonweaith of Massachusetts
Andover
i x City/Town of No.Andover CT 2025
System Pumping record
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DEP has provided thi,3 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 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.
A. Facility Information ---- -
Important:When
filling out forms 1. System Location:
on the computer, "
Y
use onl the tab - 1(°.�..___ "_ ..
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code ------
2. System Owner.
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. ° _
Name _ __.- ------- --------- -- _ __....
etum
Address(if different Lom location)
No.Andover MA
Gity/Town State Zip Gode
Telephone Nu,niber
B. Pumping Record
1. Date of Pumping Daten"2. Quantity Pumped:
G Ions
3. Component: Cesspool(s) eptic Tank ] Tight Tank _� Grease Trap
i Other(describe): ---- ----_ -
4. Effluent Tee Filter present? Yes Po If yes, was it cleaned? Yes ] No
5. Observed condition of component pumped: ..?
6. Syst Pumped By: �
N e ( Vehicle License Number
Stew..... __ _...
Company
7. Location where contents were disposed.
20 So MiII..St, rtadfort MA ;
nature puler Date
........ ----
Signatuoe of Receiving Facility(or attach facility receipt) Date
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