HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 781 WINTER STREET 8/29/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of AUG 2 9 2022
System Pumping Record TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Form 4
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 left ht
A. Facility Information BUILDING: rout back side rear left right
Important;When DECK: under
filling out forms 1. System Location:
on the computer, �7&1 �
use only the tab /
key to move your Addr SS's
cursor-do not 7.
use the return City/Town
�*y
key. Zip Code
2. System Owner:
ub
Name
idwn
Address(if different from location)
City/Town Slate Zip Code
y� - �6�- �
Telephone Number
B. Pumping Record
1. Date of Pumping Date - -- 2. Quantity Pumped: -
Gallons
3. Component: ❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -- --
4. Effluent Tee Filter present? ❑ Yes 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. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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