HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 340 FOSTER STREET 9/1/2026 Town Of hWh Andover
Commonwealth of Massachusetts
z _ City/Town ofSEP 14 02
Systern Pumping Record
5 Farm 4 ear
e aient
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
infori-nation must be substantially the sane as that provided here, Before using this form, check with your
local Board of He2lth to determine the form they use. The System Pumping Record roust be. submitted Io
the local Board of Health or other approving authority within '14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information taousc-_w. frontC)a?k'
- w Side rear lefC E;l�
y BUILDING: frofit side rear left
_f t Ir;l-it
Important: When DECK: under
q out forms1. Systern Loca.tiC7
on they cornputor, •
use only the lab � �
key to move your Address _
cursor-do nor MA
usethe relurn —__.__.__._..____ __._..._-- . ' ___._.._ _ __..._._ _ _.. —__.___._._ ,...__-__ --
key. Cilyff-own State Zip Code
�;..._...__.. 2. System Owner:
Varrle
- _
renvn f/�`�
Address (If different frorY) locallon} _,-...----_—_—_--
MA
cityl,rown State
Zip Code
Telephone Number
P. Pumping Record f
1. Gate of Pumping Gal�Ons�_,... _—__----..
p 9 Date - —_- ____ 2. Quantity Pumped:
3. Component: (❑ Cesspool(s) "optic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? [ ] Yes - rUo If yes, was it cleaned? ❑ Yes Ej No
5. Observed condition of corr7p n nt pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD31Z
arrrr, vehicle License Number
Q a to s o n tt e r p r I5 E;S, Inc.
_------
Cornpany
7. Location where contents were disposed:
GLSD
........... _ _cr<'wHaul,r
Ogle
.._._.._ ....... --
Slgnalure of Receiving Facility(or attach facility receipt) Date
15form4.docc 1 t112 System Pumping Record -Pagoq 1 or 1