HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 286 RALEIGH TAVERN LANE 6/8/2022 i,tCEIVED
o Commonwealth of Massachusetts
City/Town of JUN 0 8 2022
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 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.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address _
cursor-do not N 6, �` n� (��%h
use the return CiWTown gas Zip Code
key.
2. System Owner.
Name
wow
Address(if different from location)
City/Town State Zip Code
Telephone 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:
�too11 _
6. System Pumped By:
Na/me I Vd*b Liomm Number
Company Ij
7. Location where contents were disposed:
G�o
Signalrure of ler Date
Signature of ReceMrig Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1