HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 550 BOXFORD STREET 5/20/2022 i
I
Commonwealth of Massachusetts RECEIVED
_ City/Town of 022
_ MAY 202
System Pumping Record NDOVER
OF NORTH A
M V Form 4 TOHEALTH 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: front ck side re left - ht
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Ocatio :
on the computer, % �QQ,�I
use only the tab k -
key to move your A ML15'g,",
cursor-do not U� 0&e�6 use the return Citylrown 'StaK Zip Code
key.
2. Sys m Owner:
h�--
ame
tetum
Address(if different from location)
i City/Town State /1�,? /� Cocje,
Telephone Number
B. Pumping Record /
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - — -
4. Effluent Tee Filter present? ❑ YNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compone t/pumped,
6. System Pumped By:
Dave Tiney - Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ion ere contents were disposed:
Signature of Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date
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