HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 169 BOXFORD STREET 7/6/2022 Commonwealth of Massachusetts RECEIVED
City/Town of JUL 0 6 2022
a System Pumping Record
TOWN Or NORTH ANDOVER
Form 4
�M 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<LDear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. Syste Location:
on the computer,
use only the tab
key to move your A dr s
cursor-do not
use the return key. ity oWn�
fate ZipCode
2. System Owner:
AV Name
iefum
Address(if different from location)
City/Town Stat 2�S Zjp Co�Je 'd
Telephone Number /Y/JQ/
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: w
Ga ons
3. Component: ❑ Cesspool(s) eptic 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 component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc n ere contents were disposed:
L
Signature of Ha Dat
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1