HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 52 NORTH CROSS ROAD 9/19/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of SEP 1 92022
a 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 substahtially 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
351.
accordance with 310 CMR 15. HOUSE: front back side rea a right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. Syste/m�Location:
on the computer, c •/ ¢/��Q CK6S
use only the tab Address
key to move your
cursor-do not tVtf ZiOLDp p Code
use the return ityfrown
State
key.
2. System Own—r:
Name
nlmn
Address(if different from location)
State �/ Zip Code
city/Town 3 — WO
Telephone Number 7
B. Pumping Record
= 2. Quantity Pumped: Gallons
1. Date of Pumping Date
3. Component: ❑ Cesspool(s) ❑ Septic 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 pumpe .
6. System Pumped By:
Dave Tiney Mass 1AA95E
Vehicle License Number
Name
Bateson Enterprises Inc
Company
7. Loc here contents were disposed:
LSD
4�
91-- 7 - -
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•PaRe 1 of 1