HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 285 REA STREET 5/20/2022 ,C\- Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
2 0 2022
Form 4 MAY
M OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. 0N REMs DUPPBAWS, but the
information must be substantially the same as that provided here. Yefore 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' fro back side rea left . ight
A. Facility Information BUILDING: ront back side rear left right
DECK: under
Important:When
filling out forms 1. System LOCat )
I�
on the computer,
use only the tab
key to move your Address
f' b�9
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner:
tab /�
A M-6 S
Name
tetem
Address(if different from location)
City/Town State � � Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date a y r 2. Quantity Pumped:
Date 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
i
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
LSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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