HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 889 JOHNSON STREET 8/29/2022 Commonwealth of Massachusetts RECEIVED
w City/Town of AUG 2 9 2022
System Pumping Record
Y p g TOWN OF NORTH ANDOVER
Form 4 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: ack side rearQ right
A. Facility Information BUILDING: .front back side rear left right
Important;When DECK: under
filling out forms 1. S Ste OC , /
on the computer, ` Cif
use only the tab
key to move your Address
cursor-do not k 5 A H G/Q(,�/S
use the return key. City/Town State Zip Code ,J
2. SE
tem Owner:
'
Name �,L//'/K�
Address(if different from location)
City/Town State Code
/- �So
Telephon umber
B. Pumping Record PLO
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1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe):
4. Effluent Tee Filter present? ❑ Yes J'No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
-Th"o ck-'-t� 4-x-- � � l��
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L n where contents were disposed:
GLSD 1<2
A2
Signature of Haul Date
Signature of Receiving Facility(or attach facility receipt) Date
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