HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 COLONIAL AVENUE 5/3/2022 ,DECEIVED
Commonwealth of Massachusetts
City/Town of MAY 0 3 2022
a System Pumping Record .,-.,VgNOF;4onmANDOVER
Form 4 HEALTH 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 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
Le /Right fro of house, Left/Right rear of house, Left/Right side of house, Under Deck
Important:When eft' Ri ht id f building, Left/Right front of building, Left/Right rear of building,
filling out forms 1. System Location. g g, g g, g g,
on the computer, a 6 M rye 1 ��--
use only the tab
key to move your A ss
cursor-do not f MA V
use the return ity/Town State Zrp Code
key.
2. Sy em Owner:Of
Name
rerun
Address(if different from location)
MA
Cityrrown State Zip Code
7 1 -- 3Q e) - a 2
Telephone Number
B. Pumping Record
1. Date of Pumping —����' � 2. Quantity Pumped:
Dat 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 F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Locati n where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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