HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 487 WINTER STREET 6/13/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of JUN 13 2022
a 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. -- --
HOUSE: fro ack side rear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. SystQ m Location:`
on the computer, ! �.9 W
use only the tab
key to move your Address
cursor-do not wo6. � �� a ��
use the return City/Town State Zip Code
key.
2. System Owner:
Name
ielwn
Address(if different from location)
City/Town State OW Zip Code
Telephone Number
B. Pumping Record _ _ 1��6d
to of Pum in 2. Quantity Pumped: —
1. Da p 9 y Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --
4 Effluent Tee Filter present? es ❑ No If yes, was it cleaned? 'kYes ❑ No
"Ieyy
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7 Loc where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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