HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 85 SULLIVAN STREET 7/20/2022 'C\- Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record JUL 2 02022
a 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 back si e ear(feft�ight
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
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
rob 2. System Owner:
Name
iermn : `d
Address(if different from location)
City[Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �- 2. Quantity Pumped: t SQ
Date 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 comp o ent pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo n where contents were disposed:
GLSD
Signature of Hauler Date '�-
54�
Signature of Receiving Facility(or attach facility receipt) Date
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