HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 BROOKVIEW DRIVE 6/10/2024 Commonwealth of Massachusetts 0\411 ,\rih Andover
City/Town of 2024
a JUN 10
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: front back side rear left(2)
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, '' `` r'
use only the tab _�C� U c ec�J
key to move your A7dress
cursor-do not � MA
use the return City/Town/T'own
key. Y State Zip Code
2. System Owner:
red Ci J
rtG
Name
ierrm
Address(if different from location)
MA
City/Town State ZI Code
G,
Telephone Number
B. Pumping Record ro. Date of Pumping 11 Date Gallons 2. Quantity Pumped:
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 pu ped:
6. System Pumped By:
Dave Tiney Ma 1AA95E Mass 1AD31Z
Name Vehl le License N ber
Bateson Enterprises, Inc.
Company
7. oc 'on where contents were disposed:
LS
Signature o auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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