HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 242 FOSTER STREET 7/20/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of JUL 2 0 2022
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
H
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 rear ght
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, )�,�0��1
use only the tab
key to move your Address y�/ /
cursor-do not `�O/�'�r 'y 0L 9�
use the return
key. City/Town State Zip Code
2, System Owner:
;4 I' tUAI-J
Name
serum A�'
Address(if different from location)
City/Town State /'� /� /� '5i Code
JI
Telephone Number
B. Pumping Record
12,
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
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:
:�
Signature of Hauler Dat
Signature of Receiving Facility(or attach facility receipt) Date
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