HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 222 BRIDGES LANE 10/31/2022 i
Commonwealth of Massachusetts RECEIVED
City/Town of
System Pum i OCT 312022
p ng Record
Form 4 TOWN OF NORTH ANDOVER
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: ont back side rear left I t
A. Facility Information
BUILDING: nt back side rear left r
Important:When DECK: under ig
filling out forms 1. System Location:
on the computer, ^^�� 1
a
use only the tab V a
key to move your Address S
cursor- notuse ,� /
key the return
urn _'
key.
City/'[-own
State
ren 2. System Owner: -ZIP Code
/1 t
Name
,emw
Address (if different from location)
— —_-----
City/Town —
State Zip Code
I elep1ot5e tau b7
B. Pumping Record
1. Date of Pumping �
Date 2. Quantity Pumped: `-J
3. Component: Gallons
❑ Cesspool(s) Septic Tank
❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No
If yes, was it cleaned? ❑ Yes ❑ No
5. O served condition of component pumped:
6. System Pumped By:
Dave Tiney
Name - Mass 1AA95E
Bateson Enterprises Inc Vehicle License Number
Company _
7. Location where contents were disposed:
LS�
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112
System Pumping Record•Page 1 of 1