HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 99 HAY MEADOW ROAD 1/31/2022 Commonwealth of Massachusetts RECEIVED
City/Town of JAN 312022
s System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH OEPARTMENT
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 t(
the local Board of Health or other approving authority.
A. Facility Information
1. Socation: Left/ Right front of house, Left/ Right rear of house, Left./right side of house, Left
C ht sldeof building, Left/ Right front of building, Left/ Right rear of building, Under deck
on the computer,
use only the tab -
key to move your Address, MA "
cursor-do not o P,
use the return key. ity/Town State Zip Code
2. System Owner:
)"j+h1
B�
Address(if different from location)
MA
City/Town State � ^� � ��i
' Telephone Number
B. Pumping Record /9 -d �d[
1. Date of Pumping
� ' Date 2� Quantity rumped: Gal on
3. Component: ❑ Cesspool(s) �eptic
Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -- ---
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componen)pumped:
6. System Pumped By:
David Tiney Mass F5821 _
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loc ' where contents were disposed:
GLSD Lowell Waste Water
Signature of Hauler Date