HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 68 CRICKET LANE 8/18/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record pUG 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: front back Id rear left ri ht
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, / _� �P,,,C( ' Ali
use only the tab 1.I7 1� '`J
key to move your Address
cursor- not / J� ,�/1
use the return
urn City/Town/Town /� ,
key. y State Zip Code
2. System Owner:
Name
urwn
Address(if different from location)
City/Town Slate Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped.Da
Gallons
3. Component: ❑ Cesspool(s) ❑ eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ YeszEl"No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
v a,
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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