HomeMy WebLinkAboutSepitc Tank - Septic Pumping Slip - 1659 OSGOOD STREET 11/28/2022 RECENED
Commonwealth of Massachusetts
City/Town of NOV 28
2022.
a System Pumping Record ��. ;p ;rr ANDOVER
Form 4 -t',1w, of�r'A� aENT
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 side) rear
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:on the computer, rr Q 55 D.Qj
�fuse only the tab T
key to move your Address
cursor-do not ��dlPl�y.eM-
use the return - - — - -- --Zip----- --
key. City/Town State Code
2. System Owner:
tab //
Name
retrun
Address(if different from location)
City/Town Stat Zip Code
Telephone Number
B. Pumping Record
l 75-O
1. Date of Pumping -L 1�' � -- 2. Quantity Pumped: -
Date Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ---
4. Effluent Tee Filter present? ❑ Yeso If yes, was it cleaned? ❑ Yes ❑ No
u
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
11 to
Signatur I Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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