HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 357 REA STREET 5/20/2022 'Lx Commonwealth of Massachusetts rjECEIVED
City/Town of
a
System Pumping Record MAY 202022
Form 4 NOR""ANDOVER
TOWN OF
�{EA►-TN 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 back erear le right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location,
on the computer, S92 ��g
J
use only the tab
key to move your Adclre4s
cursor-do not
use the return
key. City/Town State Zip Code
2. SysteT Owner:
rxee&j
Name
ietan
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping J 2. Quantity Pumped:
Date 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 where contents were disposed:
GLSD `
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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