HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 312 FOSTER STREET 6/17/2022 Commonwealth of Massachusetts RICE"'ED
v City/Town of 2022
System Pumping Record JUN 1
Form 4 TO\NN 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: Lfron back side rear left,right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System
^Locati .
on the computer,
use only the tab
key to move your AdXye)-XHt
cursor-do not ���
use the return Ci y/Town Mate Zip Code
key.
rab 2. System, Owner:
I'
tlk
Name
return
Address(if different from location)
CitylTown State ode
��� ZiL_Co�le�
T�ephone Number
B. Pumping Record
1 _
1. Date of Pumping Date 4eptic
2. Quantity Pumped: Gallons
3. Component: ElCesspool(s) Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
r
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo here contents were disposed:
GLSD oe
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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