HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 110 OLYMPIC LANE 5/21/2024 Commonwealth of Massachusetts Torn 01 4c�r�h Andover
City/Town of
System Pumping Record MAy 21 2024
Form 4 @/+�
M v .��„•V�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 back side rear le right
A. Facility Information BUILDING: t back side rear eft right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab mo c G �
key to move your Add ess ^
cursor-do not ; ,Af,,L / MA D YS
use the return City/Town State Zip Code
key.
2. S171,
m Own r
VQ ('tStrf�
Name
ern Address(if different from location)
MA
Clty(Town State 2ipCode
ir
Telephone Number
B. Pumping Record
1 Date of Pumping �� Z 2. Quantity Pumped.
Date 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. Observedndition o component pumped:
0D(-1`xt
6. System Pumped By:
Dave Tiney Ma s 1AA95E Mass 1AD31Z
Name Vehi le License>14mber
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
LSD
Signature of Hauler Date
Signature of Receiving'Facility(or attach facility receipt) Date
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