HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 DEER MEADOW ROAD 11/6/2025 Town
I . .........
o Andover
L� Commonwealth of Massachusetts
c Y City/Town of NOV V 14 202
a S
ystcm Pu mping Record
Form r rrr 4
, 1 epa
rtMent
DEP has provided this fora) for use by local Boards of Health, Other forms may be used, but the
information rnusl f:)e substantivally the same is lih at provided here Before using IN(; form, check with your
local Board of Health to deterr�nine the form) they use. The System Purnping Record must be, submitted to
the local Board of Health or other appmvincf authconIy wifflin 1 el days frond -he purnpiny date in
accordance with 310 C;MR 15 351 _._.._ ec
_ .__._-_ .__.
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HOUSE: fror7tde rear Icfrt riff
A. Facility Information BUILDING, front gr
important:When
(BECK: under
HIIIng
of) onet lffopuler'
e tab 1 tei7 Location:
y,
us ltic corn a f . (�<_ .-S 4: ✓�. ""
hey IQ move YOW Addrrj,s
<irr;or do("lot (VA
u i t' I it f r p;l4J r n ... .,_ _....... --..... ............._ "44���//''wG^^"V--- __ _...._.._ .._._...__
..;il frown - ......._....._...
key- v slate Zip Code
2. System Owner.
1 _
a, arfilf _.._G -_-__-----
Address (if drffercant from looa(ion)
MA
__
Yfrown Slale If)
Tale one tJurr bar
......
B. Pumping Record
1 Date: of P u rn p i n g ---- �-�- " ..__._..._ C�u a n C i t P u n��r e c'i
Dale y Gallons
3 C'ornponent; Tir, r,i d; rank
.�
_) Cesspool(s) Sc p ri tic Tah [� Crease trap
[_] Other (describe-;) _._-___ -_---_._ __._._.__
4. Effluent Tee Filter presen[? E] `(es No If yew,, was it cleaned? Yes (.� to
5. Observed condition of ccornponent f^^;u, rnpecf.
6 S stern 1_'1
�irnped By:
ave Tin Y.._...__ ___.__._ Mess 1AAOcE, Mass 1AD31Z
N*- \lehriclf, l_Irense urnk"7e.r
Baf�sor7 E:r7f��rf�ris�s, if�r;.
,ompany
7_ LcD-(ion where contents were disposed
>Iglialrire o6 Fier„civing F -aci{i(y (or ;nl(ar,l� farihty rrcw,IG>I) Date
forma doC� 11ft Syslern Purnf,oin3 Record P,,3 e 1 cof 1