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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 18 JOHNNY CAKE STREET 5/20/2022 tECEIVEU 'C\_ Commonwealth of Massachusetts City/Town of MAY 2 p 2022 ao System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT WM 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: fron bac side re left ight A. Facility Information BUILDING: front back side rear left right DECK: under Important:When filling out forms 1. Sy tern Loca ' n: on the computer, /(�� use only the tab U Coke- key to move your Addr ss cursor-do not v�o�� _ ©A�J use the return City/Town State Zip Code key. 2. System Own r Name ierwn Address(if different from location) City/Town State Code Telephone Telephoneber B. Pumping Record 1. Date of Pumping Date J �� 2. Quantity Pumped: Gallons� 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pu ped: IY�✓d'. 6. System Pumped By: Dave Tiney _ Mass 1AA95E Name Vehicle License Number Bateson Enterprises Inc Company 7. Locati here contents were disposed: LS E:.-Al- on-- Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1