HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 178 BRIDGES LANE 1/31/2022 Commonwealth of Massachusetts AECEIVEI.
City/Town of
System Pumping Record JAN 2022
Form 4 TOWN OF NORTH ANDOVEP
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe 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 Inform" ation
1. Syste J�bFation: Left/Right front of house, Left/Right rear of house, Left/right side of house, eft
Rig side building, Left/Right front of building, Left/Right rear of building, Under deck
on the computer, /2
use only the tab
key to move your Adorpsk �q
cursor-do not VV6L— MA V C�
use the return ityrrown State Zip Code
key.
Il 2. System Owner:
Y �es4 �R
ame
Address(if different from location)
MA
City/Town State Zip Code
�/�- � � _--�-
Telephone Number
B. Pumping Record (
1.
/ �
f Pumping / 2. Quantityum ed: G Date o ate P p 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? ❑ 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. Loc ' where contents were disposed:
LS Lowell Waste Water
Signature of Hauler Dat