HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 140 CHRISTIAN WAY 6/17/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
o a
System Pumping Record JUN 17 M2
Form 4 TOWN 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: front back side rea W) right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, I
use only the tab L
key to move your Add s
cursor-do not i�}/r
use the return /'r"key. City/Town State Zip Code LLL
2. Syste Owner:
,� /s
ame
ie�mn i'
Address(if different from location)
City/Town State/109 Zip de
y�� �-- 3 g
Telephone Number
B. Pumping Record (le-13
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component. ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - — --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componen pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7 Loc ' w re contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record •Page 1 of 1