HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 90 SPRING HILL ROAD 1/31/2022 Commonwealth of Massachusetts RECEIVED
City/Town of JAN 312022
s System Pumping Record
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/91W rear o use, Left/right side of house, Left
Right side of building, Left/Right front of buildirig,`Left Righ re of building, Under deck
on the computer, -90 -SPA
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use the return C'ity/Town} � ' t State Zip Co
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2. Syssem Owner:
llf,t�� )14 6,
Name
ranm
Address(if different from location)
MA
City/Town Zip Code
I
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Telephone Number
B. Pumping Record 0-C) /- -
1. Date of Pumping Date 2• Quantity Pumped: Gain V lJ
I 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:
— owd
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
LSD Lowell Waste Water
Signature of Hauler Date