HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 23 FOREST STREET 1/31/2022 Commonwealth of Massachusetts RECEIVED
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 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 house, Left./right side of house, Left
Right side of building, Left/Right front of building, Left Right rear if building, Under deck
on the computer,
use only the tab
key to move your Adde
cursor-do not 7/✓IL� t ��� �_ MA
key.
use the return City/Town State Zip Code
2. Sys4em Owner:
Name
ream
Address(if different from location)
MA
Cityrrown State Zip Code
9 c/
Telephone Number
B. Pumping Record
400
G
Date G
1. Date of Pumping 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present9*Yes ❑ No If yes, was it cleaned? eYes ❑ No
5. Observed condition of component_pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. ;�LSSDI_owell
here contents were disposed:
Waste Water
=l � -ter
Signature of Hauler Date