HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 194 RALEIGH TAVERN LANE 6/13/2022 &N Commonwealth of Massachusetts RECEIVED
City/Town of JUN 13 2022
aSo System Pumping Record TOWN OFNORTH 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. - -
HOUSE: front back side eft right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location-
on
�-/') f
on the computer, /� / &k1)1'
ThFI/key use only the tab �.( �U� -----
to move your A dres
curs �ow `
cursor-do not +�`
use the return 'City/Town State Zip Code
key.
,n
2. Sy t� �
Name
iemin
Address(if different from location)
City/Town State odn
Telephone Number
B. Pumping Record �j l
1. Date of Pumping ~" 2. Quantity Pumped: �
Date Gallons
3. Component: ❑ Cesspool(s) ( Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe). —
f 4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
9—xK
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. catio where contents were disposed:
GLSD
-- 2
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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