HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 167 GRANVILLE LANE 11/14/2025 10"
nO ° MAndover
Commonwealth of Massachusetts
City/Town of NOV 14 2025
- System Pumping Record
DEP has provided this form for use by local Boards of Health. Other farms may be used, but the
n(orr-natior) must be substantially the same as that provided hers,. Before using this form, check with your
local Board of Health to deterr-nine the form they use. The System Purnping Record must be suUrl Med to
the local Board of Health or other approving authority within 14 days fron7 -,he pumping date in
accordance with 310 CMR 15.351.
HOUSE: fro1) brick sl'* r Ie, rifgh
A, Facility irlforrT at'joll BUILDING: front back side rear left rigr,t
Important:When DECK: Ur7dE?I'
MlIng out forms i System Location
on the cornpuler, /` - ►/�pM �^y,�}
use only I h o r a b
key Io move your Address
cursor •do not Y MA
use the reluin _-. _ -- -----. ----- --- _ --.--
- -... -------- ---_
(:;I I y/T o w n state ate _._-__.-......_.
key. 71p Coda.
2, Syste,rn Owner:
wr- rvarne
re0rn `y
----.._-...__ _.-_..--.__ _ ..... __..
Adc'1ro8s (if dilferonl born location)
MA
Cf ly/row sla1e
7e Dip Code
lP p one Nurnber
B, Purnping Record
1, Date of Pumping pale--�._.___._ ----- 2. Quantity Pumped'. Gal
lons
s ----------
3. Component ( ] Cesspool(s) [ eptic Tank ❑ Tic hl Tank Grease "trap
Other (describe) ....
4. Effluent Tee Filter present? E.) Yes __ IVo If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
y�y
6. rt� Pumpt✓d Ely
n-ave l iney --- - - ----- _Mass 1AA95E Mass 1A 1Z
fVame Vehicle License rVt tuber
-.
Bale son Enterprises, Inc
cornpany
- tlon wfer� contents were dispdisposedl_a "
Signa(ufo of Hauler e(
1)a
tie
_._- ----_ --- -.--- --- ----_ __.
-_ __ ----
Signature o eceivinq Facility (or aflac;h (��Cility receipt) Date --�-
51orm4.doc 11112 Syslern Pumping Record Page 1 of 1