HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 DEER MEADOW ROAD 9/19/2022 � Commonwealth of Massachusetts RECEIVED
City/Town of SEP 1 92022.
System Pumping Record 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: front back sid rear eft, i�ht
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System L.Rcatio
on the computer,
use only the tab 3-2
key to move your Address
cursor-do notmm
use the return City/Town State Zip Code
key.
2. System Owner:
rab
Name
ietmn
Address(if different from location)
City/Town State Zip Code
—S63
Telephone Number
B. Pumping Record qq // J
61 O�Z
1. Date of Pumping Date 2 Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 4Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Y as-k 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:
GLSD
Signatu f Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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