HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 339 ABBOTT STREET 1/31/2022 :�L\ Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record JAN 312022
Form 4 TOWN OF NORTH ANDOVER
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 t(
the local Board of Health or other approving authority.
A. Facility Information
1, System Location: Le ht fro use, Left/ Right rear of house, Left/right side of house, Left
Right side of buildin , Left Righ front building, Left/ Right rear bf building, Under deck
on the computer,
use only the tab 237 '4
key to move your Address
cursor-do not -d MA
use the return
key. 4titylTown State Zip Code
2. Syst m Owner: /
0 1
Name
renm
Address(if different from location)
MA
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: 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. Location where contents were disposed:
LSD Lowell Waste Water
Signature of Hauler Date