HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 11 BARCO LANE 5/13/2024 Commonwealth of Massachusetts f110
11
':wth Andover
City/Town of
= System Pumping Record MAY 13 2V
;F Form 4
M
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 ac side rear le right
A. Facility Information BUILDING: front back side rear a right
Important:when DECK: under
filling out forms 1. System Location:
on the computer,use only the tab 1 I� "(—CO
key to move your Ad res
cursor-do not
,ol3pr MA
use the return City/Town State Zip Code
key.
Q2. System Owner:
1�let,
Name
reran
Address(if different from location)
MA
City/Town State�L Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D to 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:
6. System Pumped By:
Dave Tiney Mass 1AA95E Aass 1AD31Z'�
Name Vehicle License Numb
Bateson Enterprises, Inc.
Company
7. +ko tion where contents were disposed:
IGLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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