HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 82 RALEIGH TAVERN LANE 5/20/2022 Commonwealth of Massachusetts RECENED
u City/Town of
System Pumping Record MAY 2 0 2022
w y�� Form 4 TOWN OF NORTH ANDOVEk
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 Info_ tion
Le4 Rig front house, Left/Right rear of house, Left/Right side of house, Under Deck
Important:When
filling out forms 1. Sy��sTTte Location: Left/Right side of building, Left/Right front of building, Left/Right rear of building,
on the computer,
use only the tab
key to move your Add ess
cursor-do not luolzWC� MA
use the return City/Town State Zip Code
key. _Q
2. S t��r. 0A) 0 _
n CJ
Name �f
Address(if different from location)
_ MA
Cityrrown State Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date2. Quantity Pumped: Gallons
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 F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Lo ere contents were disposed:
GLSD
- 2
Signature of Hauler— Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1