HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 77 SUGARCANE LANE 6/10/2024 Commonwealth of Massachusetts ° °c��AndOVer
City/Town of
System Pumping Record 1 2024
Form 4
PEP has provided this form for use by local Boards of Health, Otherorms may be used, but the
information must be substantially the same as that provided here. More 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 ide rear left gh
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, 1
use only the tab �r1
key to move your Address
cursor-do not MA 6�k4
use the return key. Citylrown State Zip Code
rye
2. System Owner:
Name
niwn
Address(if different from location)
MA
Cltyrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: I
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 condi ion of component pumped:
Q0 rn1c,
6. System Pumped By:
Dave Tiney Mass 1AA95E N*ss 1AD31Z"
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
(GLS�
1\ ► �l� L�
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
15form4.doc• 11112 System Pumping Record•Page 1 of 1