HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 FULLER MEADOW ROAD 6/13/2022 IC.\- Commonwealth of Massachusetts RECEIVED
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 CM 15.351. ••- -- --
HousE: fr ack side rear eft right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. Sy em Lqoatiqran n
on the computer,
use only the tab --
key to move your Aless.,"
cursor-do not
use the return City/Town tate Zip Code
key.
2. Sy tem Owner:
t 1n-/
Name
iemin
Address(if different from location)
City/Town State (94
Zip JCo�g— �- C
Telephone Number
B. Pumping Record AMN;76( 2,�21. Date of Pumping Date 2. uantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -- ----
4. Effluent Tee Filter present? ❑ Yesrlo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pum ed:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ion here contents we a d' osed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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