HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 901 JOHNSON 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. l$t11 the
information must be substantially the same as that provided here. Before usin 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. •• ��o�ntback
ck side rear�eftig tA. Facility Information B side rear ight
Important:When
DECK: under
filling out forms 1. System Location.
on the computer, j \_ (`
use only the tab clot '�6yj,Soy, J
key to move your In
cursor- not � MA
use the return
urn L).
key. Ci y/Town State Zip Code
2. Syste Owner:
Name
rerun
Address(if different from location) .
MA
City/Town Slate Zip C de
� - M(
Telephone Number
B. Pumping Record
1. Date of Pumping ' Z -IZ`{ 2. Quantity Pumped: /g� --
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): 1
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? /jam Yes ❑ No
5. Observed condition of component pumped: ((
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
Name Vehicle License N mber
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GL
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date -
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