HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 138 OLD CART WAY 4/25/2023 RECEIVED
Commonwealth of Massachusetts
City/Town of APR 2 52023
System P u r71 p i n g 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 C M R 15.351. -
HOUSE: front bac<9b rear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, !.q G 'b� rV ��
use only the lab 1!�b
key to move your Address
cursor•do not N
use the return City/Town State Zip Code
key.
2. System Owner:
iN
Lisp __ Yers
Name
nlwn '
Address(if different from location)
City/Town . State Zip Code
fir- y t22
Telephone Number
B. Pumping Record
1. Date of Pumping glq(z,3 2. Quantity Pumped: /��
Date 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:
OorMGI
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. tion where contents were disposed:
GLSD
Signature of (�`
9 Date
Signature of Receiving Facility(or attach facility receipt) Date
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