HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 137 BRIDGES LANE 5/21/2024 Town of Noah Andover
Commonwealth of Massachusetts
City/Town of MAY 21 2024
System Pumping Record
Form 4 G�, partment
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 left- rdn
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 tab �� % • BPS n _
key to move your Address Ij
cursor-do not U.f�Cd L�� MA
use the return
key. City/Town State Zip Code
2. System Ownef:
-_� Name
rnu�r `
Address(if different from location)
MA
Cityrrown State ZI Code
Telephone Number
B. Pumping Record
1. Date of Pumping DSe fd L 2. Quantity Pumped: GallonsS
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:
br
6. System Pumped By:
Dave Tiney M s 1AA95E Mass 1AD31Z_
Name Ve le Glcense er T
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLS
<4o At
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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