HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 SOUTH CROSS ROAD 1/31/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record JAN 312022
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
CEP 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. syste tion: Left/Right front of house, Left/Right rear of house, Left/right side of hou , Left
Rig side f building, Left 1 Right front of building, Left/Right rear of building, Under deck
on the computer, , �c
use only the tab w
key to move your Address /
cursor-do not a, L MA O r
use the return ity/Town State Zip Code
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2. System Owner:
Name
renm
Address(if different from location)
MA
Citylrown State / Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D te� / 2. Quantity Pumped: �y
Gallons
3. Component: ❑ Cesspool(s) (septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): 111
4. Effluent Tee Filter present? ❑ Yes A<O
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. Locati where contents were disposed:
LS Lowell Waste Water
Signature of Hauler Date