HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 953 JOHNSON STREET 10/7/2022 Commonwealth of Massachusetts F?ECE►VED
City/Town of
System Pumping Record TOWN
OCT 072022
Form 4 yE,q�H DEPNORTH ANDOVER
ARTMENT
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 ba sid rear left ht
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. Sy t10� J
on the computer,
use only the tab
key to move your Address ® /�
cursor- et not
use the r et �1//(J/F��
urn
key. City/Town State
Zip Code
2. Sys m O ner:
rob � like
Name /J/J
ie2in
Address if different from location)
City/Town
State ip Code
Telephone Number
B. Pumping Record 1. Date of Pumping — 11<6 /'/
Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
9 El Grease Trap
❑ Other (describe).
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned?
❑ Yes ❑ No
5. Observed condition of component pu ped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name
Vehicle License Number
Bateson Enterprises Inc
Company --
7. L ation ere contents were disposed:
GLSD
Signature of H er — --c;2/ t
Date —
Signature of Receiving Facility(or attach facility receipt) Date
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