HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 137 BRIDGES LANE 8/29/2022 L Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
Form 4 AUG 2 9 2022
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other forni4EA6T4-MEFiWMEt0e
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 bCside rear right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, 13� iz /S�-.S
use only the tab ��J (O
key to move your Address
cursor- not / �. iAA�
use the return
urn City/Town State
key. Zip Code
2. System Owner;
ab n /VV
Name
nrarn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 5-0
1. Date of Pumping Date , 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tank Tight
g ❑ Grease Trap
❑ Other (describe): -
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
xk'rlVw
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L tion where contents were disposed:
GL D
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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