HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 314 CLARK STREET 1/31/2022 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 tc
the local Board of Health or other approving authority.
A. Facility Information
1, System Location: Left/Right front of house, Left/ Rlght rear of house, Left./right side of house, Left
Right side of building, Left/ Right front of building, Left/ Right rear of building, Under deck
on the computer,
use only the tab I
key to move your Address
cursor-do not �C��y MA
use the return key. City/Town State Zip Code
2. System Owner:
No V- �kA.e aS-�- L-G V�SCQ ee
Name
rertm �`
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record b (
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:
Nof vim\ \zyQ.
6. System Pumped By:
David Tiney _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7."Signature
contents were disposed:
Was ater
Date