HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 FARNUM STREET 10/7/2022 Commonwealth of Massachusetts RECEIVED
City/Town of OCT p 7 2022
a System Pumping Record TOWN OF NORTH ANDOVER
Form 4
HEALTH DEPARTMENT
�M
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.
A. Facility Information --
Left/Right front of house, Le`� Rig rear of hous Left/Right side of house, Under Decl
Important:When
filling out forms 1. Location:stem Left/Right side of building, Left/Right front of building, Left/Right rear of building,
System �
on the computer, 1:aA 1 l�� ��-- lj
use only the tab
key to move your Address
cursor-do not MA
use the return City/ own State Zip Code
key.
2. System Owner:
Name
rerun
Address(if different from location)
MA
CitylTown
State Zip Code
-�� -
Telephone Number
B. Pumping Record
1. Date of Pumping Date
. Quantity Pumped: Gallons' ~ �r�----
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition oMcponent pu ped:
Vr
6. System Pumped By:
Dave Tiney — Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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