HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 90 WINDSOR LANE 1/31/2022 : Commonwealth of Massachusetts RECEIVEL
City/Town of JqN g 12022
t System Pumping Record
Form 4 TOWN OF NORTH ANDOVER.
HEALTH DEPARTMENT
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 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.
k Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left fight side f house, Left
Right side of building, Left/Right front of building, Left/Right rear of buildin eck
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cursor-do not /U67 � hebu MA ( //'i use the return City/Town
key. State Zip Code
2. System Owner:
ED
Name
rerun
Address(if different from location)
MA
Cityrrown Staten Zip Code
Telephone Number
B. Pumping Record /)-/3
1. Date of Pumping Date — 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yev�o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pump d.
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
G D Lowell Waste Water
Signature of Hauler Date