HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 154 ROCKY BROOK ROAD 4/29/2024 ..�:, Town 0iot�.h Andover
Commonwealth of Mass�a'chus•etts
City/Town of __ APR 2 9 Z024
' System Pumping Record
' Form 4 D P altment
Hea�Ln
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 bac side 0 left right
A. Facility Information BUILDING: front back side rear leh right
Important:When DECK: under
filling out forms 1. System Location:
on the compu r n j �� n
use only the labab �'"l V
key to move your Address
cursor•do not \ N4L� MA �(�CIS,—
use the return C 1"
key. City/Town Slate Zip Coda
2. Syste Owner:
rd
e
Name
nnm \
Address (if different from location).
MA
city/Town Stale
Zip Code
EMS
Telephone Number
B. Pumping Record
1. Dale of Pumping oa-� f i — 2. Quantity Pumped:
e 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:
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA9
Name Vehicle Licens Number
Bateson Enterprises, Inc.
Company
7. ca 'on where contents were disposed:
(GLSD
rjl�' qh/zy
Slgnalufe of Hauler Dale
Signalure of Receiving Facility(or attach facility receipt) Date
15form4.doc- 11/12
System Pumping Record Page 1 of t