HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 26 LONG PASTURE ROAD 7/29/2024 � Gomm Tav�n Andover
onwealth of Massachusetts
City/Town of aut- 2 g 2024
System Pumping Record
Form 4 �,��,pa r n�ent
Hea�t�
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: 5rn
back side rea le right
A. Facility Information BUILDING: back side rear right
Important:when DECK: under
filling out forms 1. System Location
on the computer,
use only the tab G
key to move your Address
cursor•do not own/��6V� _ MA I ��
use the return CII (T
key. y Stale Zip Code
41D 2. System Owner:
�i
Name
roan
Address (if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dale 1 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 condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E ass 1AD31
Name Vehicle License Numb
Bateson Enterprises, Inc.
Company
7. lion where contents were disposed:
G L S D
dX_ � iZy
Signature of Hauler Date
Signature of Receiving Facility(orattach facility receipt) Date
t5form4.doc• 11112 System Pumping Record•Page 1 of 1