HomeMy WebLinkAboutSeptic Tank - pump chamber - Septic Pumping Slip - 990 JOHNSON STREET 8/29/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
a System Pumping Record
AUG 2 9 2022
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other foFMALrMj)j1VAF3M"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 sid rear eft right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. S tem Locaon:
on the computer, _
use only the tab
key to move your Add r ss
cursor-do not
use the return City/Town State Zip Code
key.
2. Sys m Owner:
Name
Juan
Address(if different from location)
ode
City/Town State!,�_ b � ���
� � —
Telephones Number b
B. Pumping Record -6-22,
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe):
4. Effluent Tee Filter present? ❑ Yes D�e If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pum ed:
3-
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7 Location re contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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