HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 232 CANDLESTICK ROAD 10/18/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of ocT Is n22
System Pumping Record rOwN OF NORTH ANDOVER
Form 4 ,1EALTH 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 side rear left right
A. Facility Information BUILDING: front back side rear le right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, a 3cZ 'K/,
use only the tab
key to move your dress
cursor- not
use the return
urn /rF// ` l•f
key. City/Town -St-ate
Zip Code
2. System Owner:
dab
Name
rerwn
Address(if different from location)
City/Town Stat Code
;6�� Y&— 9/
Telephone Number
B. Pumping Record 16-9 2
1. Date of Pumpingv r —
Date 2. Quantity Pumped: Gallons
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 El No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc ion here contents were disposed:
LSD.
Signature of Hauler Da e
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112
System Pumping Record •Page 1 of 1