HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 79 ROCKY BROOK ROAD 1/31/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
system Pumping Record JAN 312022
Form 4
TOWN OF NORTH ANDOVER
yEALTH 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. System Location: Left/2R!,,gh', ouse, Left/ Right rear of house, Left/right side of house, Left
Right side of building, L R ht front f building, Left/ Right rear of building, Under deck
on the computer,
use only the tab co 9
key to move your A dr ss
cursor-do not MA `L/
use the return
key. i�ty/Town State Zipdeb
2. Sys Owner:
VA tj! ) '- /
Nafne
Address(if different from location)
MA
Cityrrown State Zip Code
332�z��
Telephone Number
B. Pumping Record
1. Date of Pumping -� — 2. QuantityPumped: / —
Date �/ p Gallons
3. Component: ❑ Cesspool(s) ,,*Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other (describe): �T
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component P
d:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
S Lowell Waste Water _
Signature of Hauler Date