HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 206 BOXFORD STREET 1/31/2022 Commonwealth of Massachusetts RECEIVED
City/Town of JAN 312022
b System Pumping Record o
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.
A. Facility Information
1. System Location: Left/Right front of house, Le Right re of . , Left/right side of house, Left
Right side of building, eft/ Right fro t of buildirig, a Right rear of building, Under deck
on the computer,
use only the tab _
key to move your Addres f
cursor-do not yy�� /
use the return 'o- v Q y MA
key. City/Town State Zip Code
2. System Owner:
L ��Q-
Name
renm
Address(if different from location)
MA
City/Town State Zip ode
a3 y � ' W
Telephone Number
B. Pumping Record
1. Date of Pumping I � 2. Quantity tyPum Pumped: Loo CU
Date Gallons 3. Component: ❑ Cesspool(s) P-1septic Tank ❑ Tight Tank ❑ Grea$e 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. /tocation where contents were disposed:
6LSD Lowell Waste Wate
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Signature of Hauler Date