HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1 SCOTT CIRCLE 3/26/2026 Town of i,' h Andover
Commonwealth of Mass-achusetts
City/Town of
System Pumping Record Health
Department
r - Farm 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same 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 days from the pumping date in
accordance with 310 CMR 15,351 ------
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A. FacilityInformation BUIILDING: Front back sTre rear Ief right
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Key, Cityrrown State, Zip Code
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7clephcne Number
. Pumping Record
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I. Date of Pumping -- _-.___ _._.._._- 2. Quantity Pumped.
Gallons
3. Component: Cesspool(s) [a -Tank ❑ Tank Tight
g ❑ Grease Trap
❑ Other (describe): ------ - -- -- _.------ ---
4. Effluent Tee Filter present? ❑ Yes No If yes, was 4 cleaned? ❑ Yes ❑ No
- -- p umped 5. Observed condition of comp—rr nt
6. ystern Pumped By:
(lave TIrt (class 1 AA9SE ass 1 AD31 Z
Name Vehlcie license Number -_. .._.__.__..
.teson nterprises, Inc.
Company
7, ocafio w cor>tents were,disposeO,
L S
Signature of Hauler Date
Signature of Receiving Facility (or attach facility recei{)t) Datp
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