HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 GRANVILLE LANE 4/13/2026 Town of N A
Core monwealth of Massachusetts Orth ndover
City/Town of
APR 17 2026
& System Pumping Record
Form
Hoafth pgq
DEP has provided this forr-n for use, by local Boards of Health, Other forDpm eau" but the
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 [hey use. The System Purnping Record must be submitted to
the local Board of Health or other approving authority within 14 days from *.he purnping date in
accordance with 310 C M R 15,351,
HOUSE: ro n back ck(�jice
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A. Facility Information BUILDING:
DECK: Linder
Important:Whan
flillng out forms 11 Sys Ai L 0;,,�t C)
on the computer, j I
use orfly the lab eoL
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key to move your Address
cursor ,do not MA
use the return
key ciiyri-owo state Zip Code
2. SAtem Owner
-------------
-�arne
Address- —(-I-t-d-j f—e-r-6-o-I born-I- o-c,a-t 1 c-)r
MA
CIl Mown — _ — ----
Zip Code
B. Pumping Record
1, Date of Purnibing 2 Quantity Pumped'. Gallons-'
Date
3. Component: ❑ Cesspool(s) ,.peptic 'rank E] Tight Tank 0 Grease Trap
[j Other (describe): ------
4, F-f-fluent Tee Filter, present? 0 Yes aeo If yes, was it cleaned? [_] Yes ❑ No
5. Observed condition of cornponen( punip
B. Sys(eivi `1L raped By.
Dave Tire Mass 1AA95E- �,LMass 1AD31Z
Naine Vehicle License N mbe-(
32leson Enl:erprises, Inc.
7. o Loca(in where c\ntents ere disposed:
LSD_
Signaltir, o( Hauler Date
Signature Of F acili(y(or @((ach facility receipt) a(e
Sys[ern Pumping Record - Pag)e 1 of 1