HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 300 FOSTER STREET 2/13/2024 Commonwealth of Massachusetts Town of North Andover
City/Town of
System Pumping Record
FEB 13 2024
Form 4
DEP has provided this form for use by local Boards of Health.,Other forma rta g}t?"tbut the
information must be substantially the same as that provided there. 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: ro back side rear e�1 right
A. Facility Information BUILDING: rout back side rear left right
Important:When
DECK: under
filling out forms 1 System Location:
on the computer, q OO S
use only the tab J
key to move your Adres
cursor- not MA 4t�,rr
use the return
urn Cit !Town
key. y State Zip Code
2. Syst;,M.O w r:
VQ
Name
r
wMn
Address(if different from location).
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
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 of component pumped.
rn
ll-
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95
Name vehicle License Numb
Bateson Enterprises, Inc.
Company
7. non where contents were disposed:
()IT'- 11
Signature of Hauler c ,I
g Date
Signature of Receiving Facility(or attach facility receipt) Date
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