HomeMy WebLinkAbout- Septic Pumping Slip - 1440 SALEM STREET 1/31/2022 : Commonwealth of Massachusetts RECEIVED
City/Town of JAN 312022
System Pumping Record
Form 4 TOWN OF NORTH ANDOVEP
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may *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 t(
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/RI ht rear of house Left/right side of house, Left
Right side of building, Left/ Right front of building, g ear of building, Under deck
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key. City/Town State Zip Code
2. System Owner:
Name J
ream
Address(if different from location)
MA
City/Town State Zip Code
G�
Telephone Number
B. Pumping Record
II cc �
1. Date of Pumping �-- 2. Quantity Pumped: J - —
Date 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? 'p4es ❑ 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 tion where contents were disposed:
GLSD _Lowell Waste Water
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Signature—of Hauler Dat