HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 65 EQUESTRIAN DRIVE 12/12/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record
Form 4 srsitiANDUVER
-TOWN Ur ,
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 ck side re �Ieftight
A. Facility Information BUILDING: ront back side rear ight
Important:When DECK: under
filling out forms 1• $ OC tlOn
on the computer,
use only the tab
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cursor-do not (5/96(
use the return City/Town State Zip Code
key.
2. S s m Owner:
ame
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Address(if different from location)
City/Town State / Z'ip Code
Telephone Number 6/ 3(/
B. Pumping Record
1. Date of Purnping Date � 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes,4NO 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. Locat' where contents were disposed:
SD
Signature of Haule Da
Signature of Receiving Facility(or attach facility receipt) Date
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