HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 767 JOHNSON STREET 10/24/2025 _ Commonwealth of Massachusetts Town Of
4 City/Town of AlOrth Andov,,
W° System Pumping Record
Y � �
._ Farm 4 OCT 2 4 2025
DEP has provided this form for use by local Boards of Health. Other fotys)�r�a, b .used but the
information must be substantially the same as that provided here. Before usin Ja b �;R ek with your
local Board of Health to determine the form they use, The System Pumping Record ust,bd @ ted 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—ba side rear 6e__ ight
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 tab Jb
_❑___._.___.__ ._ V °
key to move your Address
cursor-do not MA
use the return
key. City(Town _ State Zip Code
2, Systegi Owner-
am a
Address(if different from location)
MA
CitylTown State _ Zip Ca/de
B. Pumping Record
_-_____.__ - --- 2. QuantityPumped'.
--_ _--
1. Date of Pumping Date p Gallons
3, Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): ______--- __�_T�.. _.____.____._____.__._ __ __� _ _...----..__.__.._-____ -----_.
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Mass 1AA95E M ss 1AD31Z
_-____,__...._.-_________.__..____...__�
Name Vehicle License Number
��....�..�.-...-_.
son Enterprises, Inc.
Company
7. Location where contents w e disposed:
-
G LSD --�- —
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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