HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 370 FOREST STREET 8/24/2020 Commonwealth of Massachusetts
City/Town of IM o to +V-� Aid Del cr RECEIVED
System Pumping Record
Form 4 AUG 2 4 2020
T F�N��Q TH ANDOVER
DEP has provided this form for use by local Boards of Health. Other forms may be IW NIRTMENT
information must be substantially the same as that provided here. Before using this orm, 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,
A. Facility Information
Important;When
filling out forms 1, System Location;
on the computer, \� /w 1 r
use only the tab / (J V
key to move your Address L's
cursor-do not No �T-r l A h �) � - M � ) T _
use the return key. City/Town State Zip Code
VQ 2. System Owner:
r�
Name
ntre
Address(If different from location)
City/Town State q -7 �.. 9 R(: Coda 4`lD`L
Telephone Number /7�, T
B. Pumping Record
1. Date of Pumping 1 02 2, Quantity Pumped:
Date111 Gallons
3. Component: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe); - ---- -
4, Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
and
6. System Pumped By:
i 1l u tyhCLIer) 1 1 -7
Name — --- _-- -
Service Pumping&Drain Co.,Ina. Vehicle License Number
S Hallbem Peru
Company North Reading,MA01864
i:.n.n:.p%w6«« .4.tv*.'.
7. Location where contents were disposed:
q/1 SOECI
Signature of Hauler Date
Signature of Receiving Facility(or attach facility recelpt) Date
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