HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 59 SUNSET ROCK ROAD 10/31/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of OCT 312022
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 rea a right
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 Add re s �-
cursor-do not �_\� [� ,,di�,✓1 _ /j %(/; '�
use the return c-�C "�I—�/V`�'/�
key. City/Town State Zip Code
2. System Owner:
tab
610-1
Name
temin
Address(if different from location)
City/Town Stat V611Zip Code
Telephone Number
B. Pumping Record n B
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ YesNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component 1pumped:
J%l.N z
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo here contents were disposed:
LSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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