HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 55 WINTERGREEN DRIVE 6/17/2022 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
Form 4 JUN 17 2022
I'lis
ANDOVER
DEP has provided this form for use by local Boards of Health. OtITOV11*M9 -McOTbut the
information must be substantially the same as that provided here. B= 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 ack side rea(f::j Night
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System tlOn:
on the computer, ,�moo,,
use only the tab ou fLee"
key to move your Address
cursor-do not
use the return ity/Town State Zip Code
key.
2. Sy m Owner:
Name
ietum
Address(if different from location)
City/Town State [� 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? ❑ Yes 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. 1 here contents wer disposed:
GLSD
Signature of Haul Date
Signature of Receiving Facility(or attach facility receipt) Date
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