HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 365 BOSTON STREET 10/18/2022 RECEIVED
IL Commonwealth of Massachusetts
w City/Town of
OCT 18 2022
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DAR
EPTMENT
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: (`back side rear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System
SOS*"
,�i
on the computer, 3 f1N S Yam" �J
use only the tab
key to move your Adddress
cursor-do not
use the return _-
key. City/Town State Zip Code
2. S ste Own r: '
dab
Name
reiam
Address(if different from location)
City/Town State
` „ „Zip Code
Telephone Number
B. Pumping Record
�6
1. Date of Pumping Date _t97�2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other (describe): -----— -----
4. Effluent Tee Filter present?;
resent? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component p mped:
I'L�rAR i,qIF
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L here contents were disposed:
GLS
_1
Signature of Hauler Date/
Signature of Receiving Facility(or attach facility receipt) Date --
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System Pumping Record •Page 1 of 1
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