HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 186 INGALLS STREET 1/31/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
b system Pumping Record BAN 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 tt
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/ Right front of building, Left/Right rear of building, Under deck
on the computer, n[/1 S
use only the tab �(j' Vt�' {+� J
key to move your Address L, _
cursor-do not 0 �� �� MA
use the return key. ity/Town State Zip Code
2. System Owner:
Name
rerun
Address(if different from location)
MA
City/Town State Zi Code
:3g
Telephone Number
B. Pumping Record )`1. Date of Pumping Da ate ✓ r 2. Quantity Pumped: ���
D Gallons
3. Component: ❑ Cesspool(s) ASeptic 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 pumped:
qxd
6. System Pumped By:
David Tiney _ _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD Lowell Waste Wate "� 1
Signature of Hauler Date