HomeMy WebLinkAboutSepitc Tank - Septic Pumping Slip - 68 TUCKER FARM ROAD 11/28/2022 Commonwealth of Massachusetts RECEIVED
N City/Town of NOV 2 8 2022
System Pumping Record
Form 4 ArH aNDOVER
APARTMENT
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 ac ' side rear Fright
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,use only the tab (0 8
key to move your Address _ n
cursor-do not q � , I/�I'"v1L�--
use the return �`
key. City/Town State Zip Code
2. System Owner.
Name
ierwn
Address(if different from location)
City/Town State Zip Code
36a -99F
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: �G1 —
Date 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 pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L tion where contents were disposed:
LS
Signature of auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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