HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 49 ABBOTT STREET 10/7/2022 NECEIVEU
Commonwealth of Massachusetts
City/Town of OCT 0 7 2022
System Pumping Record 'OWN OF NORTH ANDOVEf
Form 4 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 CM 15.351. ---
HOUSE: front back si ar left i h
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, / /
use only the tab p/®
key to move your Address
cursor-do not �;'— v
use the return ity/Town State Zip Code
key.
2. System Owner:
Name
iar�n
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date / 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -
4. Effluent Tee Filter present? ❑ Y No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component umped:
6. System Pumped By:
Dave Tiney Mass 1AA95E _
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca � where contents were disposed:
SD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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