HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 41 BEAVER BROOK ROAD 8/29/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
a System Pumping Record AUG 292022
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other foMfi9�li�y �1���, 1�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 <ide ear eft right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System/Location:
on the computer, gi
/51�✓►�e
use only the tab aressC/"
key to move your Q
cursor•do not fate Zip Code
use the return City/Town
key.
2. Sy tem Owner:
ie
Name
reuen
Address(if different from location)
Slate Zip Code
City/Town
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe).
4
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of com onent pump d.
tvg
6. System Pumped By:
Dave Tiney Mass 1AA95E
Vehicle License Number
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLSD
Signature of H r Date
Signature of Receiving Facility(or attach facility receipt)
Date
System Pumping Record•Page 1 of 1
t5form4.doc• 11/12