HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 CRICKET LANE 4/29/2024 Commonwealth of Massachusetts TQnoNodh Andover
City/Town of
System Pumping Record APR 2 9 M4
Form 4
pp___4,F, - M; e, artnnent
DEP has provided this form for use by local Boards of Health. Other�ft�I"S ay be sed, 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 rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the lab e C;V--
key to move your Address
cursor•do not �� MA
use the return
key, ityrrown Stale Zip Code
2. Sys em wner:
L Ct (k r C"
Name
nnrn
Address (it diHerenl from location).
___ MA
Cilyrrown Slate Zip Code
C11- ���-
Telephone Number
B. Pumping Record
1. Date of Pumping Date i2 L 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? r Yes ❑ No If yes, was it cleaned? �] Yes ❑ No
5. Observed condition.of component pumped: j
AA;P rnX(
6. System Pumped By:
Dave Tiney Mass F5821 ass 1AA95E
Name Vehicle License Num r
Baleson Enterprises, Inc.
Company
7. ion where contents were disposed:
GLS
� �1�riliy
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Dale
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