HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 15 SULLIVAN STREET 3/12/2026 TOw
n � 1cii1th Andover
` Commonwealth of Mass-
achusetts
City/Town of MAR 16 2026
s z, y tem Pumping Record
Farm 4
DepartMent
DEP has provided this form for use by local Boards of Health. Other farms may be used, but the
information must be substantially the sarne 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 drays from the pumping date in
accordance with 310 C'MR 15 351 __. - — -- _- - __ ... -.__
HOUSE: (fr n3' back side mar Irsft right
A. Facility Information BUILDING: front back side rear lefrt right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, !
use only the tab r r/ (f L"--
ey to move ycrtir c dre+ss
cursor-do riot � g
uge the return 1....—
._.___.._. _.__ _ .. ___.. ...__.._. MA_.._ ...___. _... ..____.. ...._ 1 {
ke City[r'own State Zip Code ._..._._--
Y
2. System owner:
rl/ Ia �
Nang,.
unrn "t�
Address (if different from location)
MA
City(T'own Stala u Zip Code _
Telepi7ane Nu nit)er
.---.._.-- _._._....___._.._...
B. Pumping Record
1. Date of Pumping -. , 1 . ..__.. ...._._- ?_. Quantity Pumped-.
Date y Gallons
3. Component: [ Cesspool(s) Septic Tank ❑ Tight Tank� Grease Trap
[] Other (describe):
4. Effluent Tee Filter present? r Yes ❑ Na f yes, was it cleaned? Yes (r J No
5. Observed condition of corm anent pumped:
6. System Pumped By:
Dave TlneY._.._.._.._..__. Mass 1AA95E ass 1AD31
Name VehlCle i_icense Numt�er
eateson Enterprises, Inc.
company
7. &t .
ere contents were disposed:
auler Date
Signature of Receiving'Facility (or attarti facility receipt)
t5form4.doc- 11/12
System Pumping f7ecnrrl -nape 1 of 1