HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 LOST POND LANE 4/25/2023 RECEIVED
Commonwealth of Massachusetts
City/Town of _ APR 2 5202"
System Pumping Record TOWN oFivini AANDOVER
Form 4 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 Syste.m 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 ack side rear(je5 right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location
on the computer, ,� L ^/
use only the tab C rO `c6 Zak 1 h
key to move your Address
cursor-do not Anuse the return m,, �key. City/To State
Zip Code
4:1
2. System Owner:
�Qn c-S C-11-1-
Name
inuro t
Address(if different from location)
City/Town .
State Zip Code
G03 -3Ys"t1&1
Telephone Number
B. Pumping Record
1. Date of Pumping Date y 2. Quantity Pumped: �9-
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
Bateson Enterprises Inc Vehicle License Number
Company
7. L 'on where contents were disposed:
GLSD
Z Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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