HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 545 JOHNSON 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 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 r 1r, Left/right side of house, Left
Right side of building, Left 1 Right front of building, Left Right rea j%uildlng, Under deck
on the computer,
use only the tab J 7-
key to move your 7;�'-z
✓ �- !/4 'v� MAcursor-do not
use the return City/Town State Zip Code
key.
IFAR2. System Owner:
rah
Name
renm
Address(if different from location)
MA
City/Town State �/ ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -—
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pum d:
�66o t�
6. System Pumped By:
David Tiney _ Mass F5821 _
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loc n where contents were disposed:
LSD Lowell Waste Water
Signature of Hauler Date