HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 173 BRIDGES LANE 6/13/2022 1C-N- Commonwealth of Massachusetts RECEIVED
City/Town of JUN 13 2022
a System Pumping Record
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: :2rt back side rear left 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 11 -7 J 3 r,' Sg :5 .N
key to move your Address
cursor-do not i4ndo �-yt
use the return key. City/Town State Zip Code
2. System Owner:
Name
mrum
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
) �oc�
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 [ -11, If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
itJv r rna
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
I
7. L where contents were disposed:
GL
Signature aule Date
i
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1