HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 GRANVILLE LANE 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: fron ack side rear (D right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 1,016 07s U/�A !�
key to move your A7;P0'4-1V-
use
cursor-do not the return City/Town State Zip Code
key.
2. S tem Owner:
P�
ame
retain
Address(if different from location)
City/Town State ip Code
�/—
T115lephone Number
B. Pumping Record
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 9
No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumpe .
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. cati where contents were disposed:
GLS
Signature of Haul Date
Signature of Receiving Facility(or attach facility receipt) Date
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