HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 901 JOHNSON STREET 8/29/2022 �L\ Commonwealth of Massachusetts RECEIVED
w City/Town of _ AUG 2 9 2022
a 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: fron back side rear le i ht
A. Facility Information BUILDING: f back side rear left right
DECK: under
Important:When
filling out forms 1. SjZtem Loc Ion:
on the computer, �� C�
use only the tab l/I � (/U V 1
key to move your Addre�� ff
cursor-do not
use the return key. city/Town State Zip Code
2. Syste wner:
Name
ie�um
Address(if different from location)
City/Town State/J Zip bode
Telephone Number v/1
B. Pumping Record
1. Date of Pumping Date 4 2• Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -- -- -- �/ -- ---
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? es ❑ No
5. Observed condition of component p�:
R-,n
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo where contents were disposed:
GLSD If
Signature of Hauler V Date
Signature of Receiving Facility(or attach facility receipt) Date
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