HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 122 FOSTER STREET 7/6/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
a System Pumping Record JUL 062022
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 bac side rear left ht
A. Facility Information BUILDING: front back sl a rear left right
DECK: under
Important:When
filling out forms 1. S stem Locat n:
on the computer,
use only the tab
key to move your dr s
cursor-do not � �/'? 6`//
use the return 'City/Town" / tate Zip Code
key.
2. System Owner:
W-2(�
Na
ielmn
Address(if different from location)
City/Town State ip Code
Y-4— �1
Telephone Number
B. Pumping Record �-1. Date of Pumping Date 2. Qu 301)2��-
antity Pumped:
allons
3. Component: ❑ Cesspool(s) Vseptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye 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 where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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