HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 150 CHRISTIAN WAY 4/29/2026 Commonwealth- of Massachusetts
City/�i�own of _
Ort Andover
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SySt 'm Pumping Record
,. Form 4 MAY 13 2026
DEP has provided this form for use by loccll Rowels of Health. other forrr�s tst�y� � � ed but t)e
y p A ct }
information must be substantially the s ,rne as tIf of rovlded here. Before using )fs m
local Board of Health to determine the form fey use. Fibe System Purnpfng Rocord must be submitted I()
the local Board of f-ieraRh of other approving r_3ulhon y within 1 r1 clays from the purnping date In
accordance with 310 CMR 15 i51D-
A. {r)tJ.`>(..: frr,�nt hack sidle rcrir i h Facility Information 3f-1ItIDING r-or hack side Ir,f, right
n,portanf,When DECK'. undei,
(Ming oW rcvms 1. System L_oc,-, lion.
on
n lhn cc7mpuler,
use hr� 16
only I lab
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cursor -do nol ��// MA
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key. Si Zip Code
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2. System Owner
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F'`ddross, (I(<7itfF rr;nl (corn loci(ion) -
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ity/T own - --._.
r1k C...,�Zi p code
t�urnber
Pumping Record
1, Date of Pum in
p 9 Onle '--_ ? (quantity Pumped'. —�----
Galfons
3. Component: —J Cesspool(s) e 7tic lank r ,( [�] Tight 'rrtnSC (�_� C,rr,�sr� Trap
Oiher (describe)' — --- /
4. Effluent Tee Filter present? ', es [ J If yes, was it cleaned? [_] Ye5 ❑ No
6. Observed condition of r orrff)orenf pumped
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6, ystern limped By:
Dave Tlr ny Mass 'IAA9 F Mass 'IAD31Z
d rT1C \/e hlClr Ligc.n,� Niirrrla itr
Qa an-Fnferpfises, Inc
Company
7, caIicn rt Oil t0nt5 werC' (Iisposr 1
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Sf�na((.iro a( 4-faulor C}alra.
- ---------- _.- _-. _._._..
Signature or Receiving f=aciliCy («r altdr,M facility receipt) Or+fu
c+rrn�.doc 11111 Sysiern Bumping Record psacjr� t of i