HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 98 FULLER ROAD 1/31/2022 : Commonwealth of Massachusetts RECEIVED
City/Town of
UV
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 tc
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right of house, ft/ Right rear of house, Left/right side of house, Left
Right side of buiidin , Left/ Rig ron o uildirig, Left/Right rear of building, Under deck
on the computer, � g J p�
use only the tab
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. Sy tem Owner:
Name
Bnm
Address(if different from location)
MA L
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date �/ 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ,�J Septic Tank ❑ Tight Tank El Grease Trap
❑ Other (describe): / —
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed Condit on of component pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7. Location where contents were disposed:
Lowell Waste Water _
Signature oof Hauler Date'�7