HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 145 CRICKET LANE 9/19/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of SEp 192022
System Pumping Record tOWNOFNORTHANDOVER
Form 4 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 CM 15.351. - -
HOUSE: ro"t�fiack side rear�e'ftight
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, I��
use only the tab ( '� 1 (` L-P • 4-L1 v
key to move your Address
cursor-do not
use the return - -- - -
key.
City/Town State Zip Code
2. System Owner:
ub
� Dy,•t��'�.
Name
miwn
Address(if different from location)
City/Town State Zip Code
' �77 1-3
Telephone Number
B. Pumping Record
1. Date of Pumping — 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspcol(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 conditio 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:
el�C'LS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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