HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 FULLER MEADOW ROAD 7/29/2024 Commonwealth of Massachusetts
10% o ' L Andover
City/Town of
System Pumping Record
Form 4 ent
e a,
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: ront back side rea pl right
A. Facility Information BUILDING: front back side rear right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, e— r ( /I t
use only the tab 2c> �u lQ{ �L k CGC., ` C
key to move your Address cursor-do not
use the return Ai ./^
� C3� tJ�- MA
key. CilylTown Slate Zip Code
2. System Owner:
Name J
mvn
Address (if different from location)
MA
Cityrrown Slate Zip Code
4�9- C-10
Telephone Number
B. Pumping Record
1. Date of Pumping 2 �
p 9 Date 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 ;onditiiomponent pumped:
Gurn��
6. System Pumped By:
Dave Tiney Mass 1 AA95E ss 1 AD31
Name Vehicle t icense Number
Bateson Enterprises, Inc.
Company
7. ntion where contents were disposed:
2� L
nr
Signature of Hauler Dale
Signature of Receiving Facility(orattach facility receipt) Date
t5form4.doc, 11112 System Pumping Record•Page 1 of 1