HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 FULLER ROAD 10/7/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record OCT 072022
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPA
DEP has provided this form for use by local Boards of Health. Other forms may PIMNW, 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: ro back side rear right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
fin the out forms 1. System location:
on the computer, /`7J `�/��
use onlythe tab —
key to move your Addr ss
cursor-do not � )
use the return key. City/Town State Zip Code
2. System Owner:
rob ba-S�\�
Name
rerun
Address(if different from location)
City/Town State Zip Code
sog - g �-1
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons -
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - ---- -
4. Effluent Tee Filter present? ❑ Ye/sff No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed cc dition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLS
Signature a Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record •Page 1 of 1
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