HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 67 RALEIGH TAVERN LANE 12/5/2022 Commonwealth of Massachusetts RECENED
City/Town of
DEC 0 5 nzz
System Pumping Record
Form 4 ro�,iN OF No'ATIr ANDOVER
HEALTH 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 side' ea(left right
A. Facility Information BUILDING: front back side rear le right
DECK: under
Important:When
1. System Location:
filling out forms y �
on computer,
o the puer,
use only the tab ,` Ie t (4�eGI1
key to move your Address
cursor-do not N, A o&)V&r
use the return Cily/Town State
key. Zip Code
2. System Owner:
aD
C-c 1 I I�eA CY\Cl
Name
mwn
Address (if different from location)
City/Town State Zip Code
F„�; 4 - 6?-
Tel phone Number
B. Pumping Record
1. Date of Pumping 2.Date Quantity
t ty Pumped: Gallons
3. Component: ❑ Cesspool(s) 0"Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): _
4. Effluent Tee Filter present? 4 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. rti n where contents were disposed:
�I zIZ2
Signat uler Date
Signature of Receiving Facility(or attach facility receipt) Dale
t5form4.doc- 11/12
System Pumping Record•Page 1 of 1