HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 168 CAMPBELL ROAD 1/31/2022 :4L\ Commonwealth of Massachusetts RECEIVED
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 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 t(
the local Board of Health or other approving authority.
A. Facility Information
1. %Fshe lion: Left/Right front of house, Left/Right rear of house, Left/right side of house,g ide building, Left/Right front of building, Left/Right rear of building, Under deck
on the computer,
use only the tab
key to move your AddLess j
cursor-do not R � MA Q I ys
use the return L ADkey.
City/Town State Zip Code
011_ 1 2. System Owner:
N me
ream ,
Address(if different from location)
_ MA
Cityrrown Stat Zip Code
qr�- L//'�- a16's
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe): — - -- —
4. Effluent Tee Filter present? ❑ Yes
,,N�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. L where contents were disposed:
6TLS,D Lowell Waste Wa r
Signature of Hauler Date