HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 FARNUM STREET 4/29/2024 Commonwealth of Massachusetts OWIR el ` .h Andover
1. !Town i owni of 2024
tl
�Aiar<< .~.6r�/; ,a='1=:: ApR 29
WY %.PL off
%A / NI/ 1W 1 vW
Farm 4
DEP has provided this form for use by local Boards of Health. Other&rr o dy 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.
A. Facility Information __ ._ _
Left/Right front of house, Left fight rear-of house, Left/Right side of house, Under C
important:out f When 1. � r Left/ Right g g g g g
fil ina out forms S tem Lo., tion: g t side of buildiri Left/Right front of building, Leff/Right rear of building,
.
on the computer,
use only the tab ---
key to move your Address
cursor-do not _ __ MA
use the return -key. State Zip Code
fit/—) 2. S tem Owner:
r�
10 y+V_ __--
ame
reran
Address(if different from location)
MA
Cityi7own Stale 7.ip Cade
Telephone Number _
B. Ptamping record
Date
1 nat . of Pumping �'— - - 2. Quantity Pum ed: -------
P p � Date p allons
3. Component: ❑ Cesspooi(s) Septic Tank ❑ Tight Tank 0 Grease Trap
❑ Other (describe): ----- - -- ----- --- —
4. Effluent Tee Filter present? [( Ye o If yes, wag it cleaned? ❑ Yes No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tines - --- Mass F5821/_ur�
Vehicle Licenseber
Bateson Enterprises, Inc.
Company ----- - --- --
7. Location where contents were disposed:
JI
LSD
Signature of Hauler Date
Sign aline of Rwm ving F;jcility(oc attach facility roc(:ipl) nkli(-— — -
15form4.doc• 11/12 System Pumping Record •Page 1 of 1