HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 316 RALEIGH TAVERN LANE 5/20/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
a
System Pumping Record MAY 2 0 2022
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. -° -- - -
HOUSE: front bac side rear left i ht
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 _
key to move your Address
cursor-do not C�
use the return C y wn State Zip Code
key.
2. Sy tem Pwn
Name
serum
Address(if different from location) 24— `� / 9 b
City/Town Sta a Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
ate Gallons
3. Component: ❑ Cesspool(s Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave_T_iney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company - — -
7. Lo here contents were d' d:
GLS
1-3
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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