HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 784 WINTER STREET 12/5/2022 RECEIVED
Commonwealth of Massachusetts 2022
City/Town of SEC 0 5
'- stem Pure in
Y J Record GOWN OF NORTH ANDOVER
S
Form 4 �jEALTH 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: back side rear left right
A. Facility Information BUILDING: 5,53nitback side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, 1 C -. P , 1 n s
use only the lab 5 hJ
key to move your Address
cursor-do not CDI�I c,
use the return City/Town/Town ` r e
key. y State Zip Code
2. System Owner:
Name
ttluin
Address (if different from location)
City/Town State Zip Code
y96
Telephone Number
B. Pumping Record
In ij1211 Zl /Opp
1. Date of Pumping g Date �/ 2• Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) (Q 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 component pumped:
l�rJcn-►a
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. qSign.t
n where contents were disposed:
r )2
Date
Signature of Receiving Facility(or attach facility receipt) Date
15form4.doc. 11/12
System Pumping Record Page 1 of 1