HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 371 STEVENS STREET 7/29/2024 ft^soh Andover
Commonwealth of Massachusetts
City/Town of JUL 2 9 2024
System Pumping Record
Form 4 nt
PEP 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 ide rear left' fight
A. Facility Information BUILDING: front c side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer,
use only the lab
key to moon your Be
s��cursor•do not L>.�
use the return MA I
key. City/Town State Zip Code
2. System O ner.
c.ne� LteS
Name
nlun
Address (if different from location)
MA
Cllyrrown Slate Zip Code
_ Telephone Number
E3. Pumping Record y
1. Date of Pumping Date 2. Quantity Pumped: Gallons Ans
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 condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E Xass 1AD31
Name Vehicle License Num er
Bateson Enterprises, Inc.
Company
7. nLfion where contents were disposed:
Signalure-of Hauler Date
Signature of Receiving Facility(or,attach facility receipt) Dale
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