HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 434 BOXFORD STREET 7/20/2022 Commonwealth of Massachusetts RE�EtvED
w City/Town of
System Pumping Record
RTH ANDOVER
Form 4 TO\NN OTH DEPARTMENT
HEAt-
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: ont back side rea a ight
A. Facility Information BUILDING: ront back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, / /
use only the tab t13 ( 13 OK
key to move your Address cursor-do not N'1
Af� � (0K
use the return City/Town State Zip Code
key.
2. System Owner: 45(tora&
reb
Name
ietwn
Address(if different from location)
City[Town State q Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Pumped: Gallons ' -
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - - -- --- -
4. Effluent Tee Filter present? ❑ Yes [S 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. Location where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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