HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 459 SALEM STREET 1/31/2022 Commonwealth of Massachusetts -DECEIVE[.
City/Town of
b System Pumping Record JAN 312022
Form 4 TOWN OF NORTH ANDOVEP
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 Locatio . Lefty Rig front of Fious Left/Right rear of house, Left/right side of house, Left
Right side of bull ng, Left/ Rig Font of building, Left/Right rear of building, Under deck
on the computer,
use only the tab `1 `� l ( �",A 4;4 (%1W'�-1
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
,n
2. System Owner:
Name
�ertm
Address(if different from location)
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Callon'
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? iYes ❑ No If yes, was it cleaned? 4s ❑ No
5. Observed condition 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:
GLSD Lowell Waste Water
Signature of Hauler Date