HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 340 FOSTER STREET 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 Syste.m 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 sid re le. right
A. Facility Information BUILDING: front back side ar eft right
Important:When DECK: under
filling out forms 1. System Location-
on the computer, J
use only the tab /
key to move your Addre
cursor-do not
use the return
key. City own' ` 1 tate Q ;1
Zip Code
2. System Owner:
' r'cl `'�j/-
Name
rrrmn r
Address(if different from location)
City/Town . State Zip Co e
Telephone Number <B. Pumping Record
1. Date of Pumping D e ✓ 2. Quantity Pumped:
Ilons
3. Component: ❑ Cesspool(leptic 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 pum ed:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name
Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc ' here contents were isposed:
LSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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