HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 437 SALEM STREET 1/31/2022 Commonwealth of Massachusetts RECEIVED
City/Town of JAN 312022
s System Pumping Record
TOWN OF NORTH ANDOVEP
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may'beused, 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/Right re ouse, Left/right side of house, Left
Rightsloe of building, Le /Right front of build* Left Left/ 'ght rear-61 building, Under deck
on the computer, s
use only the tab
key to move your Add r ss I /
cursor-do not
use the return MA
City/Town State Zip de
key.
2. Sy tem Owner:
Name
ratan
Address(if different from location)
MA
Cityrrown State Zip Code
f?49 )
Telephone Number
B. Pumping Record
1. Date of Pumping D to / ~ 2. Quantity Pumped: Gallons )
3. Component: ❑ Cesspool(s) _E�teptic 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. Location where contents were disposed:
LSD Lowell Waste Water
Signature of Hauler Date