HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 165 FOREST STREET 5/10/2022 Commonwealth of Massachusetts RECEIVED
City/Town of MAY 1 2022
} System Pumping Record
Form 4 �,.,,,,, ;� 'N,DgIH ANDOVER
'w, �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 t(
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
f
A. Facility Information HOUSE: E
n back side rear left
Important:When BUILDING: ront back side rear left
filling out forms 1. Sy tern Location: DECK: under
on the computer, /,6 T��D1 n 5Z
use only the tab (S1/ /"L)/ 'LV
key to move your AdIcirels 1�i� 0
cursor-do not l y
use the return key. City/Town State Zip Code
2. System Owner:
tab r- AJ6�4M'6
N me
etun
Address(if different from location)
City/Town State/ 1 — n
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) iseptic 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 component purr ed:
6. System Pumped By:
Dave Tiney _ - Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Signature of Ha r Date