HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 314 CLARK STREET 3/19/2026 Town Of
; l rth AndOver
Commonwealth of Massachusetts
:- City/Town of
_ Wl System Pumping
em Record Form a
t.: ti j
DEP has provided this forrn for use by local Boards of I-iealth other forms may be usedttpw
information must be substantially the sarne as that provided here. Before using This form, check with your
local Board of Health to determine the forrn they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the purnping date In
accordance with 310 CMR 15.351 ---_ ------ _
.__.. HOUSE: front back sicir, rear left right
��"� side rear Ief""�
A. Facility Information BUILDING: front.(f_. r right
Important: When 7FCK: 1dLl"
filling out forms 1. Systen1 I_.D ation:
Computer,on ilre
use onlythe lab
r
key to move your Address
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r usor-do no( C it !lQTown ,f� __ , _ _....,, . _ _ _._-_ _ _-- ..__.___, . ...
cu( or(:return _ ! _.. (ClC'e"- MA
-------
key. - Y State Zip Code
2. Systern owner:
J`�� Na m ehirmn y
Address (if different from location)
MA
C�ifyrTown Slates Lire Code
TelFphorte fl(trnhe(
B, Pumping Record
1. Date of Pumping -r�lf3 � _...__-_----- ?. Quantity Pumped:
Galians
3. Component: ,] Cesspool(;) Septic "funk( [� Tight Tank ❑ Grease Trap
[_] Other (describe): ____
4. Effluent Tee Filter present? [_) Yes No If yes, was it cle—,ined? [� j Yes [_j hJo
5, observed condition of cor tponent purnped:
JvrA 41 _
5. System Pumped By:
Dave a,'- 1A�g5E � Mass 1AD31Z
Name Vehit Ir ce( Tiber
eateson Enterprises Inc.
Sompany
7. -ation where cont(nCs were disposed
_.._.
S�gna ro o Hauler
Signature of ReceivIng Facility (or altach facility receipt) Date
t5form4.doc- 11/12 System Pumping Reec«r<f Page 1 ol1