HomeMy WebLinkAboutSeptic tank - Septic Pumping Slip - 101 COLONIAL AVENUE 7/20/2022 -C\ Commonwealth of Massachusetts RECEIVED
u City/Town of
System Pumping Record
ORTH ANDOVER
Form 4 TOWN OTN DEPARTMENT
HEAD
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 C M R 15.351. -- -
HOUSE: (T ack side rear(EDright
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, r of - �b IOVi I �
use only the tab _
key to move your Address
cursor-do not
use the return - - - - —— -- -- - -- -
key.
City/Town State Zip Code
2, System Owner:
!ab
AL
Name - ----- --
aelwn
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record �+
1. Date of Pumping Date — r ('10'20-t 2• Quantity Pumped: Gallons��
3. Component: ❑ Cesspool(s) E4Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - ----
4. Effluent Tee Filter present? ❑ Yes VNO If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
l�c1Z�
i
6. System Pumped By:
I
Dave Tiney Mass 1AA95E
Name Vehicle License Number
` Bateson Enterprises Inc
Company
7. L cation where contents were disposed:
GLS
I
1 7— �
Signature of Hauler A, Date
i
Signature of Receiving Facility(or attach facility receipt) Date
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