HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 165 FOREST STREET 4/25/2023 Commonwealth of Massachusetts RECEIVED
City/Town of APR 2 52023
System Pumping Record -
F o s 4 TOArN OF`1OR t H ANDOVER
H,;,.I,q 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: ron back side rear left i ht
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, r
use only the lab ++1C0� Pdr es�
key to move your Address _ — —
cursor-do not N � — ("
use the return City/Town State �^ Zip Code
key.
2. Syc�e
,,,1')el
m Owner:
,b
L I( �'G� ksn
r --
Name
nlan '
Address(if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record ,� 9
1. Date of Pumping Date — 2. Quantity Pumped:
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 contents were disposed:
GLSD
k_—
Signature o auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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