HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 MARIAN DRIVE 8/29/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of AUG 2 9 2022
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
M
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: front back side ear ft Ig
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, qL
use only the tab �__ Ci.( ! ___��f
key to move your Address
cursor-do not
use the return key. City/Town State Zip Code
" 2. System Owner:
Name
awn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ' Quantity Pumped: �O U
Date Gallons
3. Component: ❑ Cesspool(s) VSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes VNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of cc m onent pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati where contents were disposed:
CG
[ '
Signature of Hauler ate
Signature of Receiving Facility(or attach facility receipt) Date
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