HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 102 SPRING HILL ROAD 10/7/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record OCT 072022
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: front back side ear left ight
A. Facility Information BUILDING: front back side rear left right
Important:When
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use only the tab �N'�
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2. System caner:
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Name
ieruin
Address(if different from location)
City/Town State Zi Code
Telephone Number
B. Pumping Record _
1. Date of Pumping 2. Quantity Pumped:
/U
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? s ❑ No If yes, was it cleaned. Yes ❑ No
5. Observed condition 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:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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