HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 734 Boxford Street 5/21/2024 � Commonwealth of Massachusetts
4:1- p oh Andover
City/Town of MAY 21 2024
System Pumping Record
Form 4 �r �;t
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 bac si_d�e��par left rig
A. Facility Information BUILDING: front back si e rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, - SS �^r_
use only the tab `7 tsj,� ) S
key to move your Address
A
cursor-do not N ��ttQ� MA n
use the return City/Town State Zip Code
key.
2. Sy tem((Owner:
pr
Q, nke,.ir�
Name
ieian
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate ) 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 Css71;;975E) Mass 1AD31Z
Name Ve umber
Bateson Enterprises, Inc.
Company
7. ron where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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