HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2189 TURNPIKE STREET 1/31/2022 W RECEIVED
Commonwealth of Massachusetts
City[Town of JAN 312022
System Pumping Record TdWN OF NORTH ANDOVER
Form 4 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: Left
�`J ht fronuse, Left/ Right rear of house, Left/right side of house, Left
Rights a of building, e / Rig fron of building, Left/Right rear of building, Under deck
on the computer,
use only the tab _]�&L) S7
key to move your -Address G
cursor-do not d 4 MA
use the return key. City/Town State Zip!Code
2. System Owner:
'!�&04a D C� �wv9w
Name
Bnm
Address(if different from location)
MA
City/Town St e Zip Code
r`q_�3&f--�3�y3
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): vv
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. ;Lnoca ' where contents were disposed:Lowell Waste Water
Signature of Hauler Date