HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 60 LONG PASTURE ROAD 4/21/2026 <f c ommc` nvvealtl,� of m<- , cf� , > tc7 Town of rtAndover
Town of
APR 3 0 2020'System Pumping
�l Y R e c:o r
Form 4
Heab Dep
DE P has provided this forrn for t.lse by IC�r al boards of Health. Other forrrus (nay be asec, >�.r
information must L)e substantirflly lhe, S erne a that providc,,d here, BOorr: using this form, CI)eck wilt) your
Ir
local Board of Health to determine the farm th uy rase The SysteM Purnping Record must b(,, r,t.,t.7rnitted Io
the local Board of Health or other --pprcwinq raulhority within 'I I days from the purnping date if)
accordance with 310 C MR 15.351
f-Ir7lJS17 from b,rck ,Irle�Ies1r rift rif,Yrt
A. Facility Information H(JILDING front hack side rear haft rq,,ht
Imr )ortant;Uvt)ef, C:
*� f',)I- f(1 i jn d �Y I
on Ole rrarnfanlr.f, P
(Ming Our fe>rr m 1. Systern o t�ltic)ti � ��,�'/�j
u,(;orily thra [at) ` 4 4 t 4
kc y[o move your Ae(drogs
--... _ -
kc,,y. ylT r)von ;rica Zip Cade
2. : ern Ow r.
Name 4?7
- _
rrprn�%�t�
/rddrrrss (if(.9ifir;rc,rul rrUr,r Icar.;allgn)
,RyffownM �,
'5 Caclr;
cic{ home burr bwr
_.
E.1,. Pumpinq Record
1, Date of Purnping Dale --- 2, Quantity Pumpe=d
Gans
3. Corraponent: [� C s�,prar._rl(s) 14 ewic -ramk (_�� Tight Tank Grease Trnp
(_W] Other (describe)
4 C'ffluerat Tee Filter present? [.._� Yr a, (� 7 yaps, was it cleanc d? Yes ( f Irlcr
5. Observed condi(ion of com ponce purnped
f
6 S 7stern Pi,arnpe,rlrBy
avrti I Irak^y. M a s 1IV-\95E-: fvlass 1AD317_
a 1Y18 \/e hVNa t...ii�uv;4., h.turn>4.r
nEe.__rp)nses Inr,
GrxaaUrtny __ __
7. !oca-Nl�n 1e e `c>n r�nI, vverl; <iispoSt,.,CJ
G L S
SlynaIWO Of t-laular 7aln
�iignature of Receiving iving Facility (or 3ltacti (aciliIy feceir,r�} -_... C)af .. .......__. _.._.
I`AwriA,d>c• 11112 `:'yslem PurnpIorl f�e�rord Prar:at7 1 bf a