HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 115 OLYMPIC LANE 10/7/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
a
System Pumping Record OCT 0 7 2022
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may a 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: ront ack side rea left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. 25:
stem LO Ion:
on the computer, �,�
use only the tab
key to move your Address
cursor-do not W6
use the return ity/Town State Zip Code
key.
2. System Owner:
tab
��6
Name
iemm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
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? ❑ Y 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. L I n ere contents were disposed.
G
2
Signature of Ha r Date
Signature of Receiving Facility(or attach facility receipt) Date
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