HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 22 TIFFANY LANE 11/28/2022 ICN Commonwealth of Massachusetts iAECEIVED
H City/Town of
System Pumping Record NOV 2 2022
Form 4 TOWN OF NUHTH 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 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 bac�e�rear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer. c
use only the tab i t
key to move your Address /� l
cursor-do not lu A�C��� 1'1 C — -- �) INC
use the return key. City/Town State Zip Code
2. SYste(n Owner:
IL rab r�G {[i l C_ e
Name
return
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1 ,(
1. Date of Pumping Date 4 2. Quantity Pumped: Gallons --
3. Component: ❑ Cesspool(s) /Z� 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 of omponent pumped:
fjor IN'"
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L6c"JJ*0Qn where contents were disposed:
GLSD
t
Sign uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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