HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 96 FARNUM STREET 5/20/2022 Commonwealth of Massachusetts RECEtvED
u City/Town of
System Pumping Record MpY 2 0 2022
a Form 4 TOWN OF NORTH ANDOVER
M 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 rear ft< -ig
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. S tem Location:
on the computer, R1 -vin .37
use only the tab
key to move your A ass
cursor-do not (,(w-v�JVrJ �
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use the return City/Town—' ' r� State Zip Code
key.
2. Sy em Owner:
A fv JOAQ,
dame
iemm
Address(if different from location)
City/Town State � Q r 46� Zip Code
Teleplione Number
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. Location where contents were disposed:
SD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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