HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 43 CANDLESTICK ROAD 6/17/2022 Commonwealth of Massachusetts RECEIVED
u City/Town of 2022
System Pumping Record �uN 1
Form 4 TcwNNORTH 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: front back sid<e r eft 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 1>--__- _ -vim`� JC ✓U �`-/
key to move your Address
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner:
rob
Name
iemin
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
�_ / u
1. Date of Pumping Date Quantity Pumped: Gallons ?S
3. Cesspool(s)ool Component: ❑ s) Septic Tank El Tight Tank El Grease Trap
P p (
❑ Other (describe): - - --- -
4. Effluent Tee Filter present? ❑ Yes [&)NO If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compo/ e� pumped: r
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location ere contents were disposed:
GLS
Signature of Hauler Date L v
Signature of Receiving Facility(or attach facility receipt) Date
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