HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 230 FOREST STREET 10/31/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of OCT 312022
a System Pumping Record TOWN OF NORTH ANDOVER
01 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: rot back side rear left r
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor- not n I
use the return
urn 1y
key. City/Town -- --��
State Zip Code
tab 2. System Owner:
i 'V" Mull t'.'c
Name
ietam
Address(if different from location)
City/Town State
CC // Zip Code
B. Pumping Record Telephone Number
`/
1. Date of Pumping lC� /_6` �� / — �
Date 2. Quantity Pumped:
Ga ons
3. Component: ❑ Cesspool(s) Septic Tank
❑ Tight Tank El Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned?
❑ Yes ❑ No
5. TObsed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name —
Vehicle License Number
Bateson Enterprises Inc
Company — —
7. Loca 'on where contents were disposed:
L
Signature of Hauler /v /
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112
System Pumping Record•Page 1 of 1