HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 314 CLARK STREET 11/28/2022 Commonwealth of MassachusettsWNW
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System Pumping Record NO
Form 4 PQWN OF NO',," ANDOVER
lrjeALT`�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 CMR 15.351. -
HOUSE: front back rear left ht
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1, System Location:
on the computer, 3)L4 e/kr �•,
use only the tab ( �j�--
key to move your Address
cursor-do not
use the return City own State Zip Code
key.
2. System Owner:
tad '
��� La►�Sc�P�
Name
mrxn
Address(if different from location)
City/Town State 01 _ I0( Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date - — 2. uantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank Ti
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes o 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
i
7. Location where contents were disposed:
LSD
72
`t
Signatur of ler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12
System Pumping Record•Page 1 of 1