HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 518 SALEM STREET 4/3/2023 RECEIVED
Commonwealth of Massachusetts
City/Town of
3
System Pumping Record fOVNIN OF NORTH ANDOVER
Form 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: front ba side rear e® right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, 1
use only the tab 5 `1 Q &A l�M
key to move your Address
cursor-do not P. An&—Vr 1 yk, Ot�ysr
use the return City/Town State Zip Code
key.
2. System Owner:
nb
1
Name
nimn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 ?'2. Quantity Pumped: oauoh nZ
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 component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Jaion where contents were disposed:
GLSD
W 3�ti��Z3
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12
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