HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 270 SOUTH BRADFORD STREET 5/2/2023 Commonwealth of Massachusetts ;�ECE►vEv
C ity/Town of �, u 2023
x System Pumping Record �: ANDOVER
Form 4 TOWN OF DEPA No,""RTMENT
HEALTH
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: fron ack side rear left righ
A. Facility Information BUILDING: ront back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, -.7,A S
use only the tab --(� G
key to move your Address
cursor•do not N _ NnAn
use the return C �
ity/Town Slate Zip Code
key.
2. System Owner:
V t
Name
nrwn '
Address (if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record
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 omponent pumped:
1vl
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7.(nGLSD
n where contents were disposed:
t lUD
Signature ofl-iauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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