HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 BANNAN DRIVE 11/28/2022 Commonwealth of Massachusetts AECEIVEc1
City/Town of _ v 2� 2022
a System Pumping Record NO
' TOVNN OF NORTH
Form 4 ANDOVER
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.sarne 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 C M R 15.351.
HOUSE: front back side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, (� ��
use only the tab / � Lnne n
key to move your Address
cursor-do not
use the returns
key.
City/Town State Zip Code
2. System Owner:
deb I`
CJ Ire V ICQn-5
Name
rrmm
Address(if different from location)
City/Town State Zip Code
_ Telephone Number
B. Pumping Record
1. Date of Pumping Date/ !� 2. Quantity Pumped: Gallon��
3. Component: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes vi No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of cm
onent pumped:
A)0 c ryt�t
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo 'on where contents were disposed:
LSD
Si ature of er Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc, 11/12
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