HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 1429 OSGOOD STREET 4/19/2022 Commonwealth of Massachusetts REcEivEL)
City/Town of APR 19 2022
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
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 CMR 15.351.
A. Facility Information_ -_ - - - --
Left/Right front of house, Left/Right rear of house, Left/Right side of house, Under Deck
Important:When
filling out forms 1. System Location: Left/Right side of bu'Iding, Left/ ig t front o building, Left/Right rear of building,
on the computer, lvg �}Cl
use only the tab l./-�
key to move your Address qs—
cursor-do not �� MA `
use the return ity/Town State Zip Code
key.
2. Sy e Owner
Name
ienan -
Address(if different from location)
MA
City/Town State `. Code��
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pum ed: Gallons
3. Component: ❑ Cesspool(s) 4NIpticTank T
ight Tank ❑ Grease Trap
❑ Other(describe): - --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes 1
0
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Locatio ere contents were disposed:
SD
SignaturakfH Her Date
Signature of Receiving Facility(or attach facility receipt) Date
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