HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 114 STONECLEAVE ROAD 1/31/2022 Commonwealth of Massachusetts RECEIVED
City/Town of JAN 312022
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Uq
DEP has provided this form for use-by local Boards of Health. Outer 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. System Location: Left/ Right front of house, Left/ Right r"r _ hous Left/right side of house, Left
Right side of building, Left 1 Right front of building, Left 1 Rtghf rear ofbuiiding, Under deck
on the computer, 1N� > r
use only the tab 0 1 7E) f6V_)E c e U(2 CJ
key to move your Address
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use the return
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urn key. City/Town State Zip Code
2. System Owner:
46 C-k`, S
Name
Address(if different from location)
MA
City/Town State Zi Code
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Telephone Number
B. Pumping Record
1. Date of Pumping 2 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other (describe):
4. Effluent Tee Filter presen7ponent
Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of co pumped:
f v vtGi .CJe
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
LrD oweil Waste Water
Signature aul Date