HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 DUNCAN DRIVE 1/31/2022 Commonwealth of Massachusetts RECEIVED
City/Town of JqN 312022
System Pumping Record10
Form 4 TOWN OF NORTH ANDOVER
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. System Location: Left/ Right front of house, Left/ Right use, Left./right side of house, Left
Right side A building, Left/ Right front of buildirig, Le /Right rear f building, Under deck
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key. City/Town State Zip Code
2. Sy tem �qer:
Name
renm
Address(if different from location)
MA
Cityrrown State Zi de
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? ❑ YexNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped
-----q,�
6. System Pumped By:
David Tiney Mass F5821 _
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7. Lo where contents were disposed:
GLS Lowell Waste Water
Signature of Hauler Date