HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 103 BRADFORD STREET 7/6/2022 Commonwealth of Massachusetts RECEIVED
N City/Town of
a System Pumping Record JUL 062o22
Form 4
TH ANDOVER
TOWN OF NOR
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 bac side rea left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 163
key to move your Addr ss
cursor-do not 7 v6i�oce L ,I�v 9� 0/b
use the return ity/Town State GtT Zip Code
key.
2. System Owner:
dab
a�q
'✓ cv
Name
iemm
Address(if different from location)
City/Town State � �/ _Zip Code
Telephone Number C�55
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s)Arseptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yey[D!o 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
Company
7. Location where contents were disposed:
GLSD
Sign o Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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