HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 135 LACONIA CIRCLE 5/10/2022 Commonwealth of Massachusetts HECEIVED
= City/Town of
MAY 10 2022
- - System Pumping Record
-C n;�.;r')F NOIRTH ANDOVEI4
Form 4
LTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with you
local Board of Health to determine the form they use. The System Pumping Record must be submitted b
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 HOUSE: front back side re eft
Important:When BUILDING: front back side rear le
filling out forms 1. System Location: DECK: under
on the computer, 122
S
use only the tab �y
key to move your Address
cursor-do not Q` `1
use the return
key. ity/Town State Zip Code
2. S stem Owner:
/,4uL, , A-
Name
Address(if different from location)
City/Town State Zip Code
I OA
Telephone Number
B. Pumping Record
1. Date of Pumping v 2. Quantity Pumped:
Date 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:
6. System Pumped By:
Dave Tiney _ _ Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati n where contents were disposed:
&LS D
Signature of Hauler Date