HomeMy WebLinkAbout- Septic Pumping Slip - 120 GRANVILLE LANE 4/25/2023 . RECEIVED
Commonwealth of Massachusetts
City/Town of APR 2 52023
System Pumping Record TOWN 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: <Sn>ack side rear <2� right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. Sys-Wm Location:
on the computer,
use only the lab
key to move your A res�s/ jy
cursor•do not A
use the return key. City/Town State Zip Code
2. Sy O n r:
Name
niwn
Address (if different from location)
City/Town . State � /�J� ip Cyde
Telephone Number
B. Pumping Record
1. Date of Pumping ate 2• quantity Pumped:
ns
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes kNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component umped:
II
6. System Pumped By.-
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo here contents were disposed:
LSD.
Signature of Haul Date
Signature of Receiving Facility(or attach facility receipt) Date
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