HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 31 VEST WAY 9/19/2022 'RECEIVED
'C\- Commonwealth of Massachusetts
w City/Town of 19nzz
System Pumping Record SEP
TOWN OF NORTH ANDOVErt
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 sidft rigD
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, 7y ,U e- I r '
use only the tab ✓1J o
key to move your Address
cursor-do not
use the return City/Town
key. - -- State Zip Code
2. System Owner:
Q
Name
ierwn
Address (if different from location)
City/Town State Zip Code
A-s't `C o9
Telephone Number
B. Pumping Record
1. Date of Pumping DateCf` i(� o-L� 2. Quantity Pumped: Gallons l ��
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 pumped:
flu
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati where contents were disposed:
GL
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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