HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 24 FARNUM STREET 5/20/2022 .iECE1VEG
Commonwealth of Massachusetts
City/Town of MAY 2 2W
a System Pumping Record O�NOR�HANDOVER
Form 4 rOwN
`'w ,,.,•�• 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.
HOUSE: front side rear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under -
Important:When
filling out forms 1. System Locaticia—
on the computer,
use only the tab '�2l
key to move your Address ,Q /
cursor-do not To A�,'/J�<� U`
use the return Ci yfTown b ate Zip Code
key.
2. System Owner:
Name
ie�wn
Address(if different from location)
City/Town Slate � / /� Zip Code
Telephone Number
B. Pumping Record /
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe). --
4. Effluent Tee Filter present? ❑ Y No If yes, was it cleaned? ElYes ❑ No
5. Observed condition of component umpe� — — -
6. System Pumped By:
Dave Tiney Mass 1AA95E _
Name Vehicle License Number
�J4
Bateson Enterprises Inc
Company
7. Loca ' where contents were disposed:
LS
Signature of Ha Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112 System Pumping Record•Page 1 of 1