HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 311 DALE STREET 4/29/2024 own ei , Andover
Commonwealth of Massachusetts
City/Town of APR 2 g 2024
System Pumping Record
Form 4 0epaltment
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: front back side rear left right
A. Facility Information BUILDING: ront back side rear leh right
`r B
Important:When DECK: under
tilling out forms 1. System Localion:
on the computer, sit 1�� �(
ICI , use only the lab - t'
key to move your A�� 1as
�I�
cursor-do not N .+Qr ,per
use the return � l `•'V MA 5
key. CilyrTown State Zip Code
2. System Owner:
Name
r
rtnm
Address (i(ditferenl from location) .
MA
Cityrrown Stale Zip Code
�� F_q_
L3 - Smoot
Telephone Number
B. Pumping Record
1. Dale of Pumping Date'r 2 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:
pI:MC
6. System Pumped By.-
Dave Tiney Mass F5821 ass 1AA95
Name Vehicle License Num er
Bateson Enterprises, Inc.
Company
7, n where contents were disposed:
GLSD
� V. gllkl Z y
Signature of Hauler Date
signature of Receiving Facility(or allach facility receipt) Oale
15form4•doc•11/12
System Pumping Record Page 1 of 1