HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 FOSTER STREET 10/7/2022 ��ECEIVE�
Commonwealth of Massachusetts
F City/Town of OCT 0 7 2022
System Pumping n Record 'OINPJ°r=NORTH ANDOVEF Y p g HEALTH DEPApTMENT
Form 4
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 back side rea le right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Looatto
on the computer,
use only the tab
key to move your Address
cursor- et not ,,��J �6 „( o f1-1
use the return Cit�r/,� !!!///lll///�l W U L State �� 0/key. Zip Code
2. System Owner:
1�
N me
retain
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping te �2 2. Quantity Pumped:
Date p allons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ YeNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By.-
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ere contents were disposed:
GLS
Signature of Haule Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112
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