HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 155 CHRISTIAN WAY 5/20/2022 Commonwealth of Massachusetts RECEIVED
City/Town of MAy 2 0 2022
a System Pumping Record TO 4 HEAI-TH OF NORTHANDOVER
Form N 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. --
HOUSE: dEt ack side rear left right
A. Facility Information BUILDING: front back side rear left rig t
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, ,
use only the tab l
key to move your A drVM�U ;14d-L�
cursor-do not _1���L'✓!
use the return key. CitylTown State Zip Code
2. Sy to )lwner:
tab /
m
teiwn
Address(if different from location)
City/Town State Zip Cope l) /'�- %�,/
Telephone Nu ber
B. Pumping Record _ /
1. Date of Pumping 2. Quantity Pumped: 6o
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --- ----- - - -- - -
4. Effluent Tee Filter present? ❑ Ye 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. L here contents were disp ed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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