HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 327 FOREST STREET 1/31/2022 Commonwealth of Massachusetts RECEIVED
City/Town of JAN 312022
System Pumping Record •
TOWN OF NORTH ANDOVEF?
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 tc
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left I Right front of building, Left/Right rear of building, Under deck
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2. SyP�em Owner:
L:�A> �Uft,44)
Name
re�
Address(if different from location)
MA
City/Town Stat ip o e
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Telephone Number
B. Pumping Record
1. Date of Pumping � 2. Quantity Pumped:
Dattee � p Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes�No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumqed.
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Locg i n where contents were disposed:
�Ls
Lowell Waste Water 0
Signature of Hauler Date