HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 495 FOREST STREET 10/7/2022 Commonwealth of Massachusetts
RECEIVED
City/Town of
System Pumping Record OCT
0 7 2022
Form 4
TOWN OF NORTH ANDOVER
HELTHDEP has provided this form for use by local Boards of Health. Other formsDmayRbe 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: on back side rear left 1 ht
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, qq
use only the tab
key to move your Address _
cursor-do not
use the return
key. Cityfr7,
State Zip Code
2. System Owner:
tab
,Name
forum
Address(if different from location)
City/Town State
Zi Code ��
Telephone Number "`�'—v�
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: / `" O cD
Date Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
9 ❑ Grease Trap
❑ Other (describe). -
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned?
❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Name Mass 1AA95E
---
Bateson Enterprises Inc Vehicle License Number
Company —
7. Location where contents were disposed:
G S
Signature of Hauler
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112
System Pumping Record•Page 1 of 1