HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 62 FARNUM STREET 5/20/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of MAY 2 0 2022
a System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
M
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. --HOU._
- - SE: ro \ back side rear left Igh
A. Facility Information BUILDING: front back side rear left right
DECK: under
important:When
filling out forms 1. Sys em Location:
on the computer, Inn
use only the tab4.
IV
key to move your JA ss
cursor-do not
use the return City/Town State Zip Code
key.
2. S stem Owner:
Name
ie�wn
Address(if different from location)
City/Town State � � �Zip Code —
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
p g 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
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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