HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 459 SALEM STREET 5/20/2022 Commonwealth of Massachusetts jjECEivEc°
City/Town of MAY 2 p 2022
System Pumping Record NORTHANDOVER
Form 4 TOWN OF
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. - - --
HOUSE• ront ack side rea lefty fight
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location,
on the computer,
use only the tab x _
key to move your Address
cursor-do not p�
use the return key. City/Town ttate Zip Code`
tab
2. System Owner:
/� 1
L ' v 1'eK
Name
tetwn
Address(if different from location)
City/Town State
3 Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat 2. Quantity Pumped: Gall O6 e 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 oo^f/�component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc _
Company
7. Local * ere contents were disposed:
LSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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