HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 571 FOREST STREET 3/18/2026 Commonwealth of Massachusetts Town of IjOrti'l A,�dover
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System Pumping Record
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Dep
DEP has provided this form for use by local Boards of Health, Other forrns may be used, . jqnt
information must be substantially the same <gs that provided here, Before using this form, check with you(
local Board of Health to determine the forn-) they urge. The System Pumping Record must brc subs-ritted (o
the local Board of Health or other approving authority within 14 days from the pumping dato In
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accordance with 310 MF 5 151 _.-
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A. Facility Information RUILDING-i' front back side real left rlg,ht
Important: When
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felling oW forrns 1 Systern Location
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use only thn tab 1* �� ���V
key to -do not A,X_ _._ ____.
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use the return _... ___.
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2. Systern OwnerW/
Name
Addross (If diKerenl Irom location)
MA
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Cify(Town Slate lif>Code
Telephone ttlurnber
B. Pumping Record
I � _------
1. Gate of Pumping ,_3 .,_. :, �. Quantity Pumped' Gallon
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3. Component: ❑ Cesspool(s) Sept,c Tank [7 Tight Tank [� Grease `Trap
❑ Other (describe): _ . _ _ ____._.__ .._....-.
4. Effluent Tee Filter present? ❑ Yes [�� No If yes, was it cleaned? ❑ Yes C_] f\Jo
5. Observed condition of component purnped
6. Systern Purnped By:
Dave fInr� --- _._-_ ..__..__ _.._ Mates _1AA95E Mass 1AD317"„
tVamP 1/r hlclr l_ir,c.r7,r Nur
eateson Enterprises, Inc..__..
7.04 ,1) n where contents were disposed:
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Sign 1 of Hauler Dale
_.__
Signature of Re ce ivinq Fercility (or irach facihiy (eceip() atr�
l5forrn4.docr 1'1/12 System Purnping Record prrtle 1 of 1