HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 211 CANDLESTICK ROAD 8/18/2022 �L\ Commonwealth of Massachusetts AECENE0
City/Town of
a System Pumping Record AUG 182022
Form 4
w„ OF NORTH ANDOVER
TO"�r%TH�EpARTMENT
DEP has provided this form for use by local Boards of Health, Other for ay a 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 ear 6ft right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. Syste Lgrat 0
on the computer,
use only the tab
key to move your ress �
cursor-do not � ELJ[ L//J
use the return City/Town State Zip Code
key.
2. S em Owner:
ab
yh�w rG�
Name
aerwn
Address(if different from location)
City/Town State Zip Code
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? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of com pone ntjpumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7 Loc here contents were disposed:
LSD 9— c;2
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
f!
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