HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 450 BOSTON STREET 4/25/2023 4N Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record APR 2 52023
Form 4 TOWN OF NORTH ANDOVER
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 bac side ear eft ight
A. Facility Information BUILDING: front back s e rear a right
DECK: under
Important:When
filling out forms 1 System Locati n:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return key. City/Town State" Zip�od '
2. System Owner:
rd l
Name
nrwn
Address(if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date �3 Z 2. Quantity Pumped: Gallo
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 conditio of component pumped: /
NO
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc lion where contents were disposed:
rGLD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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