HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 336 BOSTON STREET 7/20/2022 -C-\ Commonwealth of Massachusetts RECEIVED
City/Town of _
System Pumping Record
JUL 2 2022
0
Form 4
M TOWN OF NORTH ANDOVER
p PARTMENT
DEP has provided this form for use by local Boards of Health. Oth1dR ay 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 left fight
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 ✓ C
key to move your Addre s �
Cursor-do not l/�� IN
¢
use the return
key. City/Town S ate Zip Code
2. 7sz,,--;>ck,4z
tem Owner:
to
Name
tetwn
Address(if different from location)
City/Town State Zip Code
4k�- a716
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
ate Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - --
4. Effluent Tee Filter present? ❑ YesOL-No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pu ped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L to here contents were disposed:
GLSD
E
Signature of Hauler jV Date
Signature of Receiving Facility(or attach facility receipt) Date
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