HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1132 SALEM STREET 7/29/2024 Commonwealth of Massachusetts . « � ��� Andover
City/Town of
System Pumping Record 2 9 2024
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 date in
accordance with 310 CMR 15.351. --
HOUSE: front back side/1"reaA-11A right
A. Facility Information BUILDING: front back side ar eft right
Important:When DECK: under
filling out forms 1. System Location:on the computer, //_;;�
5i-L-use only the tab
key to move your Address
cursor-do not d1i) 1g�'��(�� MA � l
use the return key. ityfrown State Zip Code
� 2. Sys em Owner. ���
/'Narfief
ream
Address(if different from location)
MA
City/Town State_ Zip Code
� / 165
Telephone Number
B. Pumping Record 415-o'(j
1. Date of Pumping 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 condition of component pumped:
6. System Pumped By:
Dave Tiney �195EMass 1AD31Z
Name Vehicle Lice ber
Bateson Enterprises, Inc.
Company
7. Loca ' ere contents were disposed:
LSD -
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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