HomeMy WebLinkAbout- Septic Pumping Slip - 450 BOSTON STREET 5/3/2022 Commonwealth of Massachusetts 4VCEtVEU
City/Town of
a - System Pumping Record ;SAY p 3 2022
Form 4 NOR_TH ANDOVEF�
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DEP has provided this form for use by local Boards of Health. Other fo rrmay 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.
A. Facility Information HOUSE: front back side rear left-)
Important:When BUILDING: front back side rear left
filling out forms 1. System Location:
on the computer, mil/
0 S DECK: under
use only the tab '
key to move your Ad ress
cursor-do not
use the return key. City/Town State Zip Code
2. S tem Owner:
(` Utlo�
' Name
re2vn
Address(if different from location)
City/Town State'^ 0- O,^ Zipp ��
Teleph/oJne Number �—
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: 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. Lo lon ere contents were disposed:
GLS
Signature of Hauler Date