HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 93 WINTERGREEN DRIVE 5/13/2024 Andover
L\ Commonwealth of Massachusetts
City/Town of t�AY 13 2024
System Pumping Record
Form 4
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: Qt
back side rear left right
A. Facility Information BUILDING: back side rear leh right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer,
use only the lab w r Qq,
key to move your Address
cursor-do not V MA Q log
the return
key. Cily/Town Stale Zip Code
r�
2. System Owner:
Name
nnrn
Address (if diHerenl from location).
MA _
Cily/Town State Zip Code
�&- 2Fsy-2otT
Telephone Number
B. Pumping Record
1. Dale of Pumping Dale 2. Quantity Pumped: Gallon
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No It yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pu ped:
0�Nit.
6. System Pumped By:
Dave Tiney Mass F5821�Numf
ass 1AA95
Name Vehicle license
Baleson Enterprises, Inc.
Company
7. lion where contents were disposed:
LSD
S�0
Signature of auler Dale
Signature of Receiving Facility(or attach facility receipt) Dale
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