HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 352 FOSTER STREET 4/25/2023 'C\ Commonwealth of Massachusetts RECEIVED
NUM- , City/Town of
F APR 2 52023
System Pumping Record
Form 4 TOWN OF NORTH ANDOVEP
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 reaIG3 right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Lati n:
on the computer. C
use only the lab oc ---_
key to move your Address
cursor•do not N _ M 4 01 �
use the return key. City/Town Slate Zip Code
2. System Owner:
Name
rrlwn '
Address(if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record La
1, Date of Pumping Dat 2. Quantity Pumped: /6WG
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:
6. System Pumped By:
Dave Tiney Mass lAA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. nLotion where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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