HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 767 JOHNSON STREET 4/25/2023 RECEIVED
Commonwealth of Massachusetts
City/Town of APR 2 52023
a 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: front back d2eyea<a right
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location
on the computer, '1r �� ^
use only the tab
key to move your Address
cursor-do not - V f
key.
use the return Cityr/T_own State Zip Code
2. System Owner:
y%
Name
rnoin '
Address(if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 13 Date ' Z3 2. Quantity Pumped: 15CX
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:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L tion where contents were disposed:
LSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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