HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 184 CARLTON LANE 10/18/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of OCT 18 2022
° 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 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 right,
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. Syste,�n Location:
on the computer, / �//►,� //__ 144'c-'
use only the tab (�f'l�G��1J
key to move your Ai re s ! _
cursor- not
use the return
urn
key. City/Town tate Zip Code
2. System Owner:
Name
mwn
Address(if different from location)
City/Town Stag Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2
Date Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s)'-'�Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - - z
4. Effluent Tee Filter present? ❑ Yeso If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componentAumped:
6. System Pumped By:
Dave Tiney _ Mass 1AA95E
Name Vehicle License Number —
Bateson Enterprises Inc
Company
7. Locatio er contents were disposed:
G D
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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