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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 NORTH CROSS ROAD 2/13/2024 Commonwealth of Massachusetts Town of Not Andover City/Town of System Pumping Record FEB 13 2924 Form 4 y,��; $"� rtment DEP has provided this form for use by local Boards of Health. Other�4N�y'Se~ied, 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 ac side rear left righ A. Facility Information BUILDING: front back side rear left right Important:When DECK: under filling out forms 1. System Location: on the computer, , /O use only the tab gl �j -C-c6ss IZ—a key to move your Address cursor-do not k{ use the return Cit /Town ` MA ©� key. City[Town Zip Code 2. S5sem Owner:,� n �KC- NCALJLCA� Name (13 stun Address(if different from location). MA City/Town State Zip Code _ Telephone Number B. Pumping Record 1. Date of Pumping DateblL 2 Quantity Pumped: l`� 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 it on of component pumped: 6. System Pumped By: Dave Tiney Mass F5821 Mass 1 AA95 Name vehicle License N mber Bateson Enterprises, Inc. Company 7. cation 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