HomeMy WebLinkAbout- - Septic Pumping Slip - 66 CEDAR LANE Commonwealth of Massachusetts O Of North Andover
- _ City/Town of EP 14 2026
yr {(
- y m Pumping Record
Form 4 � ` �
,M Department
DEP has provided this form for use by local Boards of Health, Other forms may be used, but the
inforn-ation must be substantially the, sane, ab trial 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: fron back ide rear Ief rif,h
A. Facility informattori BUILDING: front ack side rear left rip�ht
Important:When DECK: under"
filling out€orms 1, System Location:
on the computer,
use only the tab C
key to move your Addreass _.
cursor-do not MA
use the return ___ __
key. City/Town State Z_ip Cade — —��__..___..._.......
2. System Ow ne>
' N a err e ..._.. _ _....._
krir/r f' 'J
- Address (if different from location)
MA
Cit /TownY —
State � Ilp Cade
Telephone Number
B. Pumping Record
_
1. Date of Pumping 2. (quantity Pumped: -_---
Dale aliens
3, Component: ❑ Cesspool(s) [q- c Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? ❑ Yes V410 If yes, was it cleaned? ❑ Yes F1 No
5, Observed condition of corriponent pUrnped: B
Vt
6. System Pumped By:
Dave Tin ey Mass 1AA95E Mass 1AD31Z
Name Vehicle License Nei ber
Bateso,n,' nte(prises, Inc,
Co any ---
7. Location where co -s. ere dispo;u::.d,
GLSD
S i g n a l u r re of Hauler Date
Signature of Receiving hacility(or attach facility receipt) Gate
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