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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 TANGLEWOOD LANE 10/17/2022 Commonwealth of Massachusetts t - City/Town of ` System Pumping Record Form 4 FNpa'C%A - �•:1N° pEp P t j%A DEP has provided this form for use by local Boards of Health. Other forms may". e 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 left right A. Facility Information BUILDING: front ba.ck side rear left right DECK: under Important:When filling out forms 1. System LOG n: 11 on the computer, 'O I ' Qt y use only the lab LL''tb/li _ key to move your Q dre cursor-do not � use the return key. City/Town State7 Zip Codle 2. S s m Own _ cAt Name rrrwn _ Ad_dress(it different from location) Cily(Town - — State ZipCode S3 566� Telephone Number B. Pumping Record 1. Date of Pumping �C ' 2. Quantity Pumped: C�� Date Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 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 co ents were disposed: GLSD K, \�1P Signature 917 a er Dat GE - Signature of Receiving Facility(or attach facility receipt) Dale 0� m�AN System Pumping Record•Page 1 of 1 e Bateson Enterprises,Inc. Invoice I I I Argilla Road Number: 39774 Andover,MA 01810 Date: 27-Oct-2022 Septic (978)475-4786 Office (978)475-1474 P.O. Number: 1727 Fax (979)474-5451 Job Description: Pump out. Order Num 39774 Serviced 17-Oct-2022 SITE — ---- BILL TO: 1241 JOB Kenneth Rakip Kenneth 10 Tanglewood Lane 10 Tanglewood Lane North Andover, MA 01845 North Andover, MA 01845 Quantity ServiceType Amount Tax Extension 1 1500 gals. Septic Tank Pumped $335.00 No $335.00 Taxable Amount Tax Rate Tax Description Subtotal NonTaxed: $335.00 $0.00 0 $0.00 Tax Exempt Subtotal Taxable: $0.00 Subtotal Tax: $0.00 Payment Terms Payment Adjustment Late Charge Upon Receipt ($335.00) $0.00 $0.00 Please Pay: $0.00 Invoice Message goes here. Payment Upon Receipt From: stl Please detach here and return the bottom portion with your payment. Kenneth Rakip 10 Tanglewood Lane Order No. Invoice No. Date North Andover,MA 01845 39774 39774 27-Oct-2022 $0.00 To: Bateson Enterprises, Inc. WC ti 111 Argilla Road �C 06�'O�NO0'*51 Andover, MA 01810 oO�r�u�P�-\V © N