HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 79 ROCKY BROOK ROAD 1/24/2023 moealth of Massachusetts RECE►vED
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System Pumping Record AN 2 42023
Folr 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
th s form for use by local Boards of Health. Other forms may be used, but the
be substantially the same as that provided here. Before using this form, check with your
Scam& to determine the form they use. The System Pumping Record must be submitted to
,Ecard of Health or other approving authority within 14 days from the pumping date in
*v0 310 C M R 15.351. -
HOUSE: front\ back side rear le right
A- Facility Information BUILDING: front back side rear left right
I m portart .'.tom-:
DECK: under
filling outi S} t Location:
on useth
e Wrbb 7_9
key to more yaw #
cursor-60 ad N /"/�tin&uer _
use the mhan "'n State Zip Code
VQ 2- System Owner:
Marne
Adwess(if different from location)
CitylTown State Zip Code
?39-
Telephone Number
B. Pumping Record /906
. Date of Pumping 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 offf component pumped:
ca(-"�
6. System Pumped By:
Dave_Tiney _ Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc_
Company
7. M�on where contents were disposed:
LSD
- - - - b—
Signat of H er Date
Signature of Receiving Facility(or attach facility receipt) Date
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