HomeMy WebLinkAboutBrooks School Grease Trap - Septic Pumping Slip - 1160 GREAT POND ROAD 8/25/2026 Commonwealth of Massachusetts
City/Town of Andover
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ug Form System Pumping Record2o`
DEP has provided this form for use by local Boards of Health. other f to
information,must be substantially the same as that provided here. Be are 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 10 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1, System Location:
on the computer,
use only the tab
key to move your Address
cursor-do t
use the return y City/Town —--_
2. S Oym wner Skate Zip Code
Name
n
Address(if different from location)
Cliif own
Stake Z Cade
B. Pumping Record Ta phone Number
I. Date of Pumping
Date 2. Quantity Pumped:
3. Component. auons
0 Cesspooi(s) El Septic Tank ❑ Tight Tank
Grease Trap
El Other(describe):
4. Effluent Tee Filter present? 0 Yes 0 No
If yes,was it cleaned? ❑ Yes n No
5. Observed condition of component pumped:
B. Syste Pumped By:
Name,
o ' t Vehicle License Number
7. Location where contents were disposed:
Sign ofhlaurer
Date
Signature of Receiving Facility(or attach facility receipt) Crate
t5f0m*doc•11/12
System pumping Record•Page 1 of 1