HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1514 SALEM STREET 7/24/2024 Commonwealth of Massachusetts wn of hoh Andover
To
City/Town of
System Pumping Record JUG 242024
Form 4
Y
h pepa�ment
PEP has provided this form for use by local Boards of Health. Ot��t���PIn 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 leftongt
A. Facility Information BUILDING: front back side rear left
Important:when DECK: under
lMing out forms 1. System Locatio
on the computer, t f
use only the lab 1�`
key to move your Addres
cursor-do not A n�tie� MA
use the return CilylTown Stale
key. Zip Code
2. Syst m Own r:
d
1
Name
mvn '
Address (if different from location)
MA
City/Town Slate
Zip Code
_ Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condilio of component pu ped:
OC tti-k,
6. System Pumped By:
Dave Tiney M ss 1AA95E Mass 1AD31Z
Name Ve 'cie License N ber
Bateson Enterprises, Inc.
Company
7. Lo ion where contents were disposed:
GLSD
? ,
Signature of Hauler Dale
Signature of Receiving Facility(orattach facility recelpl) Date
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