HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 130 MARIAN DRIVE 10/18/2022 'LN Commonwealth of Massachusetts ,IECE►VED
City/Town of T 1 g2022
System Pumping Record OC
Form 4 TOWN OF NORTH ANDO
VER
HEALTH DEPARTMENTT
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 back sid rear eft right
A. Facility Information BUILDING: front back side ear -rett right
Important:When
DECK: under
filling out forms 1. Sy tem Location:
on the computer, _,/Vu
use only the tab lJ AJ—/f �(/
key to move your gddyess
cursor-do not 6 �' )
use the return City/Town vwC State l�� v
key. Zip Code
2. System wner:
41 AL
Marne
mwn
Address(if different from location)
City/Town State
G ` p Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped. —
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank El Grease Trap
❑ Other (describe): -A
4. Effluent Tee Filter present? Yes [INo 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. L where contents were disposed:
GLS
Signature of H e
D
Signature of Receiving Facility(or attach facility receipt) Date
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