HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 158 FOREST STREET 8/18/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record AUG 182022
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: <aER>ack side rear left Cright
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. Syste ocatio
on the computer, / %
use only the tab
key to move your Ajd-,dre _
cursor-do not
use the return
key. City/Town State Zip Code
2. Sysitem Owner:
rob T_,M-/
N e
iemm
Address(if different from location)
City/Town State Zip Code
Telep�ione Number
B. Pumping Record ���
1. Date of Pumping 2. QuantityPumped: —/
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --
4. Effluent Tee Filter present? ❑ Yes VNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component p mped:
);I
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc on w e contents were disposed:
LSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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