HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 112 FOSTER STREET 7/6/2022 Commonwealth of Massachusetts RECEIVED
City/Town of JUL 0 6 Z02Z
a System Pumping Record TOWN CF NORTH ANDQVER
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
i accordance with 310 CMR 15.351. -- --
HOUSE: front back side re left-right
A. Facility Information BUILDING: front back side r ar left right
DECK: under
j Important:When
filling out forms 1. System Locat
on the computer,
use only the tab
key to move your
cursor-do not
use the return �y/Town State Zip Code
key.
2. System Owner:
tab
V&�
rerom me
Address(if different from location)
City/Town State / / D Zip Code
Telep one Number
B. Pumping Record
2 A&j.
1. Date of Pumping pate 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
1
i 5. Observed condition of component pu ped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. rLSD
here contents were disposed:
oel
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record •Page 1 of 1