HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 895 FOREST STREET 10/24/2025 Commonwealth of Massachusetts Town of NOM Andover
City/Town of
a = _ System Pumping Record OCR 202
Farm 4
it
DBP has provided this form for use by local Boards of Health. Other forms may be ,
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 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 316 CMR .351. HOUSE: front back id; rear•— ripfeft
— -- 15.351,
h
A. Facility Information BUILDING: front back side rear left right
Important;When DECK: under
filling out forms 1. System Location:
on the computer, �- r �'e �, t
use only the tab "'t" �
key to move your Address
cursor-do not
use the return MA
key. City(Town State Zip Code
?_. System w er:
r (
Name
Address(if different from location)
MR, _
City/Town State d✓ Zip Code —
_ i
------ _...
-telephone Number
B. Pumping Record
1. Date of Pumping aat� �� -- -- 2. Quantity Pumped
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): ---------- __ ---------_-__
4. Effluent Tee Filter present? ❑ Yes,-L21 o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped.
6. Sys Pumped By:
da ELT lneey— — _--_..______._--___-- Mass 1PA95E M s 1AD31Z
Na e Vehlcle License Nunn er
Batson E�terprises Inc.
Compa'�y
7. LocatJQn where contents were disposed:
LSD ..
Signature of Hauler Date —
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1