HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 150 BRADFORD STREET 10/7/2022 I,ECovC-wJ
Commonwealth of Massachusetts
City/Town of 0c, 0 2022
a System Pumping Record TOWN OF NORTH ANDOVEF'
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: fro - ack side rear eft right
A. Facility Information BUILDING: front back side rear le right
Important:When
DECK: under
filling out forms 1. System Location:d
/on the computer, / wit /t L. zDuse only the tab J , C/� t�
key to move your Addless ���
cursor-do not
use the return it (Town `
key. y State Zip Code
2. System Owner:
rab
Name
rerwn
Address(if different from location)
City/Town State��� � � Zin Code
Telephone Number UUy
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
allons
3. Component: ❑ Cesspool(s) Aseptic Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes �No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of com onent pumped:
6. System Pumped By:
Dave Tiney _ Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLSD
- 3— -2,
Signature uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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