HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 427 WINTER STREET 2/13/2024 'C'N Commonwealth of Massachusetts ��,�
City/Town of of North Andover
System Pumping Record 2024
Form 4 FEB 13
DEP has provided this form for use by local Boards of Health. Other forms may tVtVA0r&t 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 ide rearleft�tA. Facility Information BUILDING: front bac side
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, r 7 Cyr� r� ��
use only the tab ` W 1•\'1�
key to move your Addres
cursor-do not 13 ��" MA es
use the return
key. y State Zip Code Cit /Town w" O
2. System Owner:
Name
Bn�n
Address(if different from location).
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
%�Zy'2� Irrsc)
1. Date of Pumping Date 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 condi ion of component pumped:
�-t Q6r c
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA
Name Vehicle License Nu—4
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
I
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