HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 DUNCAN DRIVE 5/20/2022 Commonwealth of Massachusetts
u W City/Town of MAY 2 0 2022
a System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
wM 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: front back side rea eft I ht
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. S stem LO tlOn:
on the computer,,^ /
use only the tab ib�v
key to move yourLW
ddr ss
cursor-do not
use the return
key.
city/I own State Zip Code
2. System Oy/n�e�rr:
Name
iemm -
Address(if different from location)
City/Town State n ^ -f Code
Telephone Number `/'�T��_
B. Pumping Record
1. Date of Pumping Date 2. 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 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati n where contents were disposed:
SD
2zl
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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