HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 136 CARLTON LANE 5/3/2022 Commonwealth of Massachusetts -iECEIVED
City/Town of MAY 0 3 2022
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
�M
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.
A. Facility Information__
Left/Right front of house, Le Right rear of house, Left/Right side of house, Under Deck
Important:When
filling out forms 1. System Location: Left/Right side of building Left- Righ rout building, Left/Right rear of building,
on the computer, c _ Qn,,,f C _ , !��
use only the tab 'N"I\ ��'�l !
key to move your Address
cursor-do not u l6 R MA
use the return City/Town State Zip Code
key.
2. System Owner:.
NaTTfe
iemm
Address(if different from location)
MA
City/Town State _o Z1Code
Telephone Number
B. Pumping Record
�,�y
1. Date of Pumping _ ate 2. Quantity Pumped. Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --- --------
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. ea€ where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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