HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 547 WINTER STREET 9/19/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record SEP 1 92022
Form 4 TOWN OF NORTH ANDOVER
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: ro ck side rear eft fight
front back side rear left right
A. Facility Information BUILDING:
DECK: under
S5�'7
Importa When
nt: 1. System Location:
filling g out forms y
on the computer,
use only the tab
key to move your Address
cursor-do not � L
use the return CityrTown State Zip Code
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2. Istem wner.
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Address(if different from location)
City/Town State Zi6V6p Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yey No If yes, was it cleaned? ❑ Yes ❑ No
.v�(
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:
LSD
Signature of Hau Date
Signature of Receiving Facility(or attach facility receipt) Date
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