HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 7 DUNCAN DRIVE 9/19/2022 Con rnionwealth of Massachusetts RECEIVED
City/Town of
o System Pumping Record SEP 192022
Form 4 OF NORTH ANDOVER
OWN
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: ro back side rear left rlg
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return Cit !Town
key. y State Zip Code
2. System Owner:
»b
Name
ie(uin
Address(if different from location)
City/Town State Zip Code
,4
Telephone Number
B. Pumping Record
1. Date of Pumping 'T ��'� . Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -- --
4. Effluent Tee Filter present? ❑ Yes LAY No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition f component pumped:
Wl4
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
I
7. Location where contents were disposed:
GLS
Signature of Hauler Date
7
Signature of Receiving Facility(or attach facility receipt) Date
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