HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 103 FULLER ROAD 5/10/2022 Commonwealth of Massachusetts RECEIVED
City/Town of 10 2022
- System Pumping Record rUN OF NORTH ANDOVER
Form 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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted 1:1
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. Sy tem Locat
on the computer, J DECK: under
use only the tab / -
key to move your ddr ss J _
cursor-do not z!t?
use the return
key. CitylTown State Zip Code
2. System Owner:
���o
Name
rerun
Address(if different from location)
Cityrrown State Zip Code
'9 V SS
Telephone Number
B. Pumping Record
CJ
1. Date of Pumping Date 2. Quantity Pumped: Gallo
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 _ _ Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo here contents were disposed:
LSD
Date
Signature of Hauler _