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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 33 CRICKET LANE 5/13/2024 Andover Commonwealth of Massachusetts T '� _ City/Town of MAY 13 2024 System Pumping Record Form 4 SS 2�t 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 ack de rear eft ight A. Facility Information BUILDING: front back side rear left right Important:When DECK: under filling out forms 1. System Loca vioo— keyn:( on the computer, 2 C �`G use only the tab J✓to move your Ad ress cursor-do not 6LV_ MA ©f c IS use the return City/Town State Zip Code key. 2. System Ow er: 1 reb C zArz1 �Ut'/� Name erwn Address(if different from location) _ MA City/Town State Zip Code Telephone Number B. Pumping Record 2 � 1. Date of Pumping Date 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 Mass 1AD31 Name Vehicle License Nu er Bateson Enterprises, Inc. Company 7. nticn where contents were disposed: Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•PaQe 1 of 1