HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 720 FOSTER STREET 7/29/2024 Tov>;n c� ��or h Andover
Commonwealth of Massachusetts 9 20z4
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City/Town of U 2
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 oate in
accordance with 310 CMR 15.351.
HOUSE: front b k side ear le right
A. Facility Information BUILDING: front bat a rear left rig t
DECK: under
Important:When
filling out forms 1. Sy a Locatio
on the computer, 44z
use only the tab
key to move your :Add ss
cursor-do not � /�'((�-- MA 5_
use the return Ci /Town State Zip ode
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2. :me
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Address(if different from location)
MA
City/Town State �/ Zi C
Telephon umber
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspo2ol(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes El No
5. Observed condition of component pumped:
W4l
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD31Z
Name Vehicle License Nu er
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD
Signature of H ler Date
Signature of Receiving Facility(or attach facility receipt) Date
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