HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 71 WINTERGREEN DRIVE 4/25/2023 RECEIVED
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ILN- Commonwealth of Massachusetts
City/Town of _ APR 2 52023
System Pumping Record I-OWN 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: Pront
back side rea left right
A. Facility Information BUILDING: back side rear le right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address cursor-do not 0• _ __— __ - _ ("c� Q
key.
use the return City/Town State Zip Code
2. System Owner:
psi - - - -
Name
mWn
Address (if different from location)
City/Town State Zip Code
9S-ICA as-
Telephone Number
B. Pumping Record
CZO
1. Date of Pumping Date 31 Z3 — 2 Quantity Pumped: 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 of component pumped:
Norm
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. ntion where contents were disposed:
i� 31311��
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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