HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 125 COLONIAL AVENUE 10/18/2022 ,jpcENED
Commonwealth of Massachusetts
City/Town of ACT 18 2022
System Pumping Record TGVNN OF NOR-fH ANDOVER
I.iEaLTH DE
Form 4PARTMENT
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. --HOU- -
SE: nt ack side rear eft right
A. Facility Information
BUILDING: on back side rear left right
DECK: under
Important:When
filling out forms 1. System Locati n:
on the computer,
use only the tab -
key to move your Add ss
cursor-do not /Vo'K4
use the return City/Town State Zip Code
key.
2. System Owner:
V��A
Name
70w)ep'
return
Address(if different from location)
City/Town State � `''[`��)�_ 7,igCO�
Telephone Number [Z.G
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 � If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component p��� - -
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc where contents were disposed:
LSD
ASignature of Haule Date
Signature of Receiving Facility(or attach facility receipt) Date
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