HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 BEECHWOOD DRIVE 10/31/2025 TO"
n 'If Nrlt,Andover
Commonwealth of Massachusetts
z
City/Town of OCT 3 1,2025
System Pumping Record
Farm 4
DF_"P has provided this 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
focal 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 CMR 15,351.
HOUSE: front back side rear left right
A. FacilityInformation BUILDING: from(front) back side rear' le righti?
Important:When DECK: Under
filling out forms 1. System Location:
on the computer,use only the tab
key to move your Address
cur
key,or-do not LyMA
.. __.___-_-______._______-__-._____.______ Stake V use the return —
Code
4 2. System Owner:
retr �
C s r e r
• Name
Address (if different from location)
MA
City/Town State Zip Cod€,
Telephone Number
B. Pimping Record
1. Date of Pumping Da �� _-- ._...... 2. quantity Pumped — '
Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes e I Flo If yes, was it cleaned? [7 Yes No
5. Observed condition of component pumped:
6. System Pump
ed By:
k
Dave Tlnel.__..__ -- Mass 1 AA95k'..,. Mass 1 AD31 Z
Name t Vehicle t_irense Number
Bateson Enterprlses, Inc.
Company
7, L . ation where contents were disposed:
1
LSD
-----
kr
Signature f Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date - —
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