HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 BEECHWOOD DRIVE 8/3/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
�= System Pumping Record AUG 0 3 2022
Form 4
4 � TOWN OF NORTH ANDOVEFS
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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address /
cursor-donot �/`D y�!� 2A
use the return
urn City/Town _ State Zip Code
key.
2. System Owner:
��f t A, af-,
Name J
Address(if different from location)
City/Town State � 7 r- Zip Code' 6 - SSA - SSS3
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 0 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:
r
6. System Pumped By:
Name Vehicle License Number
430 r4 c zrk S s��•-���c
Company
7. Location where
rntents were disposed:
A/ I,
Signature of Ham^ Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
k