HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 196 SUMMER STREET 12/22/2022 Commonwealth of Massachusetts RECEIVED
r City/Town of DEC 2 2 2022.
a System Pumping Record
TOWN OF NORTH ANDOVER
Forni 4 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: < ron 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 SL4 rVt 1M e(_ S
key to move your address
cursor-do not ' , AJ(jV'er � Q�g ys use the return City/Town S tate
key. Zip Code
2. System Owner:
reb
t mcz Jos loci
Name
return
Address(if different from location)
City/Town State Zip Code
j'��
Telephone Number
B. Pumping Record
1. Date of Pumping Date /2 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
g El Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
00f_N C_\
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7 noGLS
n where contents were disposed:
Signat e H er Date — --
Signature of Receiving Facility(or attach facility receipt) Date
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System Pumping Record•Page 1 of 1