HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 EQUESTRIAN DRIVE 1/31/2022 ,�L\ Commonwealth of Massachusetts RECEIVEL,
City/Town of JAN 312022
System Pumping Record TOWN OF NORTH ANDOVEl
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Otter forms may be'used, but the
information-must be substantially the same as that provided here. Before using.this form,check with you
local 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.
A. Facility Information
1. System Location: Left/Right front of house, Left/ Right re use, Left/right side of house, Left
Right side of building, Left/ Right front of building, Left/ ght re f building, Under deck
on the computer,
use only tab ` ps4-12 rwj / yP
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to move your Address
cursor do return not
use the return ✓l,2G ri ,- h MA
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ity/Town State Zip Code
2. System Owner:
Name -
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Address(if different from location)
_ MA
City/Town State Zip Code
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Telephone Number
B. Pumping Record _
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 condition of component pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Lo here contents were disposed:
4LSDI�)Lowell Waste Water
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Signature of Hauler V Date