HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 26 SHANNON LANE 12/12/2022 Commonwealth of Massachusetts RECEtvED
City/Town of
System Pumping Record DEC 122022
Form 4 NORTH ANDOVER
TOWN OF
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: fron bac ide rea 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, 5k���
use only the tab I C.S�
key to move your Address
cursor-do not
use the return City/Town State G 1 R H
key. Zip Code
2. System Owner:
I�o�C_ ^
Name
iemin '
Address(if different from location)
City/Town State cc Zip Code
GS- 1-
Telephone Number
B. Pumping Record
1. Date of Pumping oaii �12Z 2. Quantity Pumped: �S ---
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
�bC M-t
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. MLD
n where contents were disposed:
Signat of uler Dat
Signature of Receiving Facility(or attach facility receipt) Date
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