HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 JAY ROAD 4/20/2026 Town of NMh Andover
Commonwealth of Massachusetts
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City/Town of
PR2 System Pumping Record 026
Farm 4
i� � t
C�E�' has provided this town for talc try local Boards of Health. Other formsms may?,
information must he substantially the; sar-ne as that provided here. Before using this faun, check with your
local Board of Health to determine the form they use. The System Purnping Record rnust be Submitted to
the local Board of Health or other approving autlhcrrity wMthin 14 days from the pur�nping Matt;In
accordance with 310 CMR 15.3`1
__._..._..... ....... HOUSE r,r toack side r e a<I.1f riptrt
A. Facility information BUILDING: front hack side rear Ief-T ril t,t
Important: WY7en
DECK: under
(Illing or.it fauns 1. Systern Location,
on fhe computer,
use only the tab
key to rnove your Adciren M ______
cursor-do not m: MA
use the return _° _...._... ..-__...---__ _........., _. ._.____ ._ _.__,_ _._ _ ...-._.----
key. CiVyn'own `t<atr, Zip Codes
faµ- 2. System Owner:
��� Narne
Address ((f different (turn locatican)
MA
City/�T'own :ift�fr3 lip Code
z
Telephone Nurnber
B. Pumping Record
90
p g ------ - Quantity Pumped:1. Date of Pum In ale "__ _-._..__ Gallons
4
3. Component: ❑ Cesspool(s) ] Septic Tar7k [1 Tight Tank ❑ Greasy 'Trap
(� Other (describe): _ ..__.___-- ----.0__
4. Effluent Tee Filter present? ❑ Yes Vej No If yes, was it cleaned? Yes ( � NCB
5. Observed condition of cornponent purnpecd
6. System Pumped By:
Gave C'In�Y........ ....... ass 1A95E Mass 1AD31Z
dame Vehicle Licenc,Y r,rnber __._.._._._...___.
Bateson Enterprises, Inc
___----- _-
Company
7, %where contents were (disposeff:
f Hauler Date
_._____-..._._._....-_...
-. ------
Signature of Receiving;._F~8acility (or attach faciwy receipt) Date _.
t5formh.doc- '11t12 System Purnping Record Faye: 1 of'1