HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 18 JOHNNY CAKE STREET 7/7/2026 j,
Commonwealth of Massachusetts Town of Not Andover
w City/Town of
W: w System Pumping Record JUL 15 2026
Farm 4
DEP has provided this form for use by local Boards of Health. Other forms aub.- ��a
information must be substantially the same as that provided here. Before using this form, hec Witft' ur
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.
HOUSE: front_ ack�ide rear left rlght
A. Facility Information BUILDING: front side rear left
DECK: under
Important:when
filling out forms 1. System Location:
on the computer, ,y -S
� �
use only the tab
key to move your Address
cursor-do not MA
use the return key. CityCTawn State Zip Code
2. System Owner:
Name
Address(if different from location)
MA
Cityfrown �^ State _ Zip Code
Telephone Number
B. Pumping Record
2. QuantityPumped:
-~--
1. Date of Pumping Datep Gallons
3. Component: (❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — - ----.---- ---__ _____
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ 'Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tines __. Mass 1AA95E Mass 1AD31Z
Name Vehicle License Number
B son Enterprises, Inc.
ompany
7. arr where c tents'we disased:
taLSp
ture of Haul r -_ Date
Signature of Receiving facility(ar attach focility receipt] Date
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