HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 509 FOSTER STREET 5/2/2023 <�N Commonwealth of Massachusetts RECEIVED
City/Town of 022GB
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTME
NT
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
)ocal Board of Health to determine the form they use. The System Pumping Record must be submitted tc
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 ack side rea le right
A. Facility Information BUILDING: front a side rear a right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, rW-
use only the lab L
key to move your �l Ad ress
cursor-do not 1� ll�
use the return City/Town Stale Zip Code
key.
„s
2. System O 5
f)e%
Name
--
ttlum �
Address(if different from location)
City/Town . Slat qz_01
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: 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 o component pumped:
M4
6, System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. on where contents were disposed:
OGLSD
Signature Dale
Signature of Receiving Facility(or attach facility receipt) Dale
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