HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 716 FOREST STREET 5/25/2023 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
Form 4 APR 2 52023
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. $CPft-ffir0WA11yWsed, 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(sD rear Q right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location
on the computer, (-bg5V S�-
use only the tab
key to move your Address _—
cursor-donot u A(N�ov(,_
use the return key. Cityfrown State Zip Code IIJJ
2. System Owner:
Name
mwn '
Address(if different from location)
City/Town State Zip Code
Svc-33 - Z3G t
Telephone Number
B. Pumping Record
1. Date of Pumping 013113 - - - 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) V Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --
4. Effluent Tee Filter present? ❑ Yes 4 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. Location where contents were disposed:
LSD
t �1 )Of L3
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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