HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 340 FOSTER STREET 7/29/2024 Commonwealth of Massachusetts Andover
City/Town of
System Pumping Record JUL 29 2024
Form 4
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DEP has provided this form for use by local Boards of Health. Other�3MtS'r1ye 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 side rear left right
A. Facility Information BUILDING: front (:ack
side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, 3 y� �� S-
use only the lab 7 /'c.ty
key to move your Address
cursor-do not
MA
use the return Gv 1
key. Cilyrrown Slate Zip Code
2. Sys em r Own :
r j
Name
r�rn r
Address (if different from location)
MA
City/Town Slate
Zip Code
_ q - I- SZC.-!6 y3
Telephone Number
B. Pumping Record
1. Date of Pumping ogle 2 2 2. Quantity Pumped: 106
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 co dition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E Aass 1AD3
Name Vehicle License Nu er
Bateson Enterprises, Inc.
Company
7, nion where contents were disposed:
� 22
Signature t Hauler Dale
Signature of Receiving Facility(orettach facility receipt) Dale
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