HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 10 TUCKER FARM ROAD 7/16/2026 Wn
Commonwealth of Massachusetts O Andover
CityhTown of
°n JUL 2
System Pumping Record
" G Farm 4
Health
DEP has provided this form for use by local Boards of Health. Other forms may be
information must be substantially the sair?e as that provided here. Before using this form, check with your
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 a c i d e rear le ft..-Qr
A. Facility Information BUILDING: front back side rear left right
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usethe return ---._.. _ ___.__-_ _ _. _.. ,______—. ._.... _.....,.__ __._.______ .__.�____._._. __ ._-. -__.__....
key. City(Town __ State Zip Code
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fiy 2. Sy stern Owner:
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- Name
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Address(if different from location)
MA
City/Town State y Zip Code
Oil
Telephone Number
B. Pumping Record
1. Date of Pumping _____.__._ ._r__._._________-_-- 2. Cuantity Pumped: .__....____.._.__.___....
Date Gallons
3, Component: [❑ Cesspooi(s) eptic 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 cornponent pumped
6. y'stem Pumped By:
have Tlney Mass 1AA95E ass 1AD31Z
----..---- _._.
arne Vehicie License Number
Bateson Enterprises, Inc
Comfaan
r Location where cant s wer
Signature of Hauler Date
Si nature of RLceivinc Facility P)
g � y(or attach facility receipt) Date
t5form4.doc- 11112 Systern Pumping Record -nacho 1 of'1