HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 180 MILL ROAD 4/25/2023 ILN Commonwealth of Massachusetts r" RECEIVED
u City/Town of
APR 2 52023
System Pumping Record
TOWN OF NOR1H 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 side rear a right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Ad s t�s F^ _ q
cursor-do not
use the return YL)key. City/To n State Zip Code
2. S em q vw er:
Name
inwn
Address(if different from location)
City/Town . State �/7 ode
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: --
Date y p 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 pumpe
6. System Pumped By.-
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc ere contents were disposed:
SD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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