HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 216 RALEIGH TAVERN LANE 8/29/2022 Commonwealth of Massachusetts RECEIVED
City/Town of AUG 2 9 2022
System Pumping Record
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: ro back side rear le right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, ( f
use only the tab
key to move your Address
cursor-do not
use the return
key.
City/Town State Zip Code
2. System Owner:
tea .
Name
return
Address(if different from location)
— -- -Code-______
City/Town State Zip J
caQV- 3d-369
Telephone Number
B. Pumping Record
1. Date of Pumping — 1 � -O�L 2. Quantity Pumped: — y
Date Gallons ea -
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - - -- - — - - - --
4. Effluent Tee Filter present? ❑ Yes E4 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc 'on where contents were disposed:
GL D
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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