HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 500 REA STREET 7/29/2024 - North Andover
-'IN- Commonwealth of Massachusetts Town of
-- C ity/Town of �UL 2 g 2024
System Pumping Record
Form 4
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. -1
HOUSE• fron back side rear left right
A. Facility Information BUILDING: ront back side rear left rig t
Important:when DECK: under
filling out forms 1. System Locati
on the computer, S�
use only the tab I
key to move your ddress Q j�
cursor-do not MA I� L
use the return City/Town� �� � .--- State Zip Code
key.
2. System O�/��
rab wG'- I L
Name
reran
Address(if different from location)
MA
Cityrrown State ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ate 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ElTight Tank [IGrease Trap
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of c onent pumped:
-S `A<
6. System Pumped By:
Dave Tine Mass 1AA95E Ma 1AD31Z
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. ation w contents were disposed:
GLSD
Signature of Hauler Dat
Signature of Receiving Facility(or attach facility receipt) Date
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