HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 139 OLYMPIC LANE 9/23/2025 Y$M1
Commonwealth of Massachusetts �' ,w ��m "•
4 .
, A17dover
City/Town of No.Andoyer
w System Pumping Record Oct 62025
Farm 4
DEP has provided this form for use by local Boards of Health. Other forms may Abe~us ; e
information must be substantially the same as that provided here. Before using this form, c Myour
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location �7
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
Name
Ell. Address(if different frr,m location)
No.Andover MA
itity/Town State Zip Code
Telephone Nurrsber
.. ........
B. Pumping Record
1. Date of Pumping <F 2. Quantity Pumped: ---�-- ------.
Da Gallons
3. Component: Cesspool(s) Septic Tank ] Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? J Yes No If yes, was it cleaned? Yes No
A
5. Observed condition of component pumped:
6. Pumped By:
Nam __------
e ` Vehicle License;Number
Ste
wart's Septic 58 So Kimball St Bradford,MA
_._.._ -- --__ __._._---._ __.____.._.
Company _-
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
--- --- -- _ --
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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