HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 24 FARNUM STREET 1/31/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of JAN 312022
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may'beused, 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 tt
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. System Location: Left/Right front of house, Left/Right r ousa, Left/ri h . house, Left
Right side of buff g, Left/Right front of building, Left/ '' hoof buildin Under deck
on the computer,
use only the tab
key to move your Address return
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cursor not //�1,��//( /CN`� �!,` ej MA IJG
use the return key. City/Town State Zip Code
2. S em wner:
Name �/'
renm '
Address(if different from location)
MA
City/Town State Zip Code
C�
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Greage Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yesl�k If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componen pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
LSD Lowell Waste Water
Signs re of Hauler Date