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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 68 TUCKER FARM ROAD 2/13/2024 Commonwealth of Massachusetts �� Andover City/Town of boy : 13a IAn F System Pumping Record Form 4 FEB 13 2024 DEP has provided this form for use by local Boards of Health. Other forms may be use S��1�nt information must be substantially the same as that provided here. Befo(e,u_, thWPA'c�heck with your local Board of Health to determine the form they use. The System PA" Record 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�bac side rear left ight A. Facility Information BUILDING: frontside rear a right Important:When DECK: under filling out forms 1. System Locati n: on the computer,use only the tab G g— key to move your Adessv cursor- not MA ©I SM use the return urn Cit frown key. y State Zip Code Q2. System Owner: kti s-z��1��� Name r ratan Address(if different from location). MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping ( Z`� 2. Quantity Pum -- - Date y ped 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 con I ition of component pu ped: orb. 6. System Pumped By: Dave Tiney Mass F5821 ass 1AA95E Name Vehicle License N ber Bateson Enterprises, Inc. Company 7. ion where contents were disposed: GLS Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1