HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 149 BRIDGES LANE 10/7/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of OCT 0 7 2022
a System Pumping Record y p g `('UWN OF I'J(7ti'TH ANDOVEI
'o Forth 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.sarne 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 rear left right
Important:When DECK: under
filling out forms 1. S stem Location:
on the computer,
use only the tab
key to move your hmsg - — -- - -- -
cursor-do not �A , �2 �L ��{_�
use the return iry or , "'- �'y"-" ,- _ I p y�
key. City/Town State
Zip Code
2. System Owner:
Name
rermn
Address(if different from location)
City/Town State Zip Code
'V KiV
Telephone Number
B. Pumping Record /0
1. Date of Pumping
p g Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic 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:
6. System Pumped By:
Dave Tiney — Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLSD
Signature auler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11/12
System Pumping Record•Page 1 of 1