HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 130 CHRISTIAN WAY 12/5/2022 �x Commonwealth of Massachusetts REr,0VED
City/Town of EC q 2p22
System Pumping Record
Form 4 TOWN OF NORTH 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 back side rear le righ
A. Facility Information BUILDING: runt back side rear left right
DECK: under
Important:When
filling out forms 1, System Location:
on the computer, 22 f
use only the tab /J� I.S At)
use
(`
key to move your Addr s I
cursor-do not A�(`dy� (1114
use the return City/Town State Zip Code
key.
2. System Own r: /
La to le l
Name
reimn
Address(if different from location)
City/Town State Zip Code
26.5- 0f -1
Telephone Number
B. Pumping Record
1. Date of Pumping l J I — 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) 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 c mponent pumped:
6. System Pumped By.-
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. nLS
n where contents were disposed:
Signa re of uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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