HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 76 GRANVILLE LANE 10/7/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System P OCT 2022
y Pumping Record 07
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 ac side rear I(f right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor- not )
use the return
urn �
key. City/Town
State Zip Code
2. System Owner:
tab
Joah"L
Name
ie2m
Address(if different from location)
City/Town Stat
tJ Zip Code
MO 7 S�
B. Pumping Record Telephone Number
71d
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) eptie Tank
ElTight Tank ❑ Grease Trap
El Other (describe):
4. Effluent Tee Filter present? ❑ Yes If y , was it cleaned?
// es ❑ Yes ❑ No
5. Observed cgndition of component pumped:
r
0l 1N�
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name —
Bateson Enterprises Inc Vehicle License Number
Company —
7. Location where contents were disposed:
L /n1
Signature a r
Date
Signature of Receiving Facility(or attach facility receipt) Date
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