HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 300 FOSTER STREET 11/28/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
a System Pumping Record Nov 28 2022
Form 4
rpWN OF N7Hl'H ANDOVER
���gqLTi DEPARTMENT
DEP has provided this form for use by local Boards of Health. &er orms 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: f�t back side rear le right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer. 2 Co
use only the tab ) eC:5a 1�[
e-11(-
key to move your Address
cursor-do not C)✓��' nl� �}
use the return City/Town ( State L Zip Code
key.
2. System Owner:
Name
renm
Address(if different from location)
City/Town State {Zip Code
aoq YOCO V
Telephones uummber�
B. Pumping Record a
1. Date of Pumping Dale -._- - — 2. Quantity Pumped. _ auohs
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - -
4. Effluent Tee Filter present? Yes If yes, was it cleaned? es ❑ No
5. Observed condition of component pumped:
1�c
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
LSD
Signature oreceiving
Date
Signature o Facility(or attach facility receipt) Date
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