HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 BROOKVIEW DRIVE 5/10/2022 _ Commonwealth of Massachusetts RECEIVED
City/Town of MAY 1 0 2022
- System Pumping Record
Form 4 TOWN OF NORTH ANDOVEI3 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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted tt
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information HOUSE: front back side rear left
Important:When BUILDING: front back side rear left
filling out forms 1. S stem Location: DECK: under
on the computer, Z0 �ll Ook i 9, /nip
use only the tab I� ` V Ct�t� i✓`� _-
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. SysOwner-
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Name
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Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record _ 2
1. Date of Pumping 'S _`�_'�1 2. Quantity Pumped: �S�U
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ------- --
4. Effluent Tee Filter present? ❑ Yes P�No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
-- — ---------— - IV ---
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc _!
Company
7. Location where contents were disposed:
LSD
Signature of Hauer Date