HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 145 COLONIAL AVENUE 10/18/2022 FiEt;trycv
Commonwealth of Massachusetts OCT 18 2022
C ity/Town of TOWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
Form 4
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 sid re left right
A. Facility Information BUILDING: front back side rear 7e-tt right
DECK: under
Important:When
filling out forms 1. S stem OC n-
on the computer,
use only the tab /
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use the return ity/Town 1N State Zip Code
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2.rab S tem Ow er:
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Name
ieiuin
Address(if different from location)
City/Town State/r ^ Zip` ode
Telephone Number
B. Pumping Record n
1. Date of Pumping — 2. Quantity Pumped:
Date Gallons
3. Component: El Cesspool(s) Septic Tank El Tight Tank ElGrease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pump
6. System Pumped By:
Dave Tiney Mass 1AA95E
t Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L here contents re disposed:
LGLSD
Signature of Hau r DateV
Signature of Receiving Facility(or attach facility receipt) Date
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