HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 14 CRICKET LANE 3/9/2026 Town of l ndover
Commonwealth of Massachusetts
c - ra City/Town of
System Pumping Record
Forin 4 Health Department
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 C M R 15.351. - -------------------------_..-------
_ HCUSE: front back side rear "leT right
A. Facility Information BUILDING: front back side rear left right
Important: When DECK: Under
filling out forms 1. System Location:
on the computer,
use only the tab f f
key to move your Address
cursor-do not - MA
use the return ---- ." —_____...__..—___._� f "
key.
CityrT'own State Zip Code
fr=v 2. System Owner:
stiff rye
s —_ _.__.
__------___.—_-
r
N a m e
ierrn ��'tt]
Address (if different from location)
MA
City/Town State --`_�_— Zip Code------------.---
Telephone Number
m t�e �'�-� ----(------------------------------------
B. Pumping Record
1. Date of Pumping Date _—_---.-----_--., 2. Quantity Pumped
3. Component: ❑ Cesspool(s) I/I Septic Tank ❑ Tight Tank ❑ Grease Trap
[_] Other (describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By: .__„_�
DaveTln Mass 1AA95E ass 1AD31�-\
Name Vehicle License Num
Bateson Enterprises, Inc.
Company
7. Vonwhere contents were disposed:
LSDSigna uler Date ---- — __
Signature of Receivin Facili yreceipt)
g g ry(or attach facility Date
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