HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 146 DEER MEADOW ROAD 10/7/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record OCT 072022
Form 4 T'OWN OF NORTH ANDOVER
HEALTH nEpART
DEP has provided this form for use by local Boards of Health. Other forms may Ked, 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 CM 15.351. --
HOUSE: fro t back side rear le Ig t
A. Facility Information BUILDING: ront back side rear left rlg
Important:When
DECK: under
filling out forms 1. System Location:
on the computer,
use only the tabI .
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
tab
�1'r-rdk
Name
emrn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date oZ�— 2 uantity Pumped:
Gallons
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 f component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc ion where contents were disposed:
GL D
�``� -
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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