HomeMy WebLinkAboutPump Chamber - Septic Pumping Slip - 261 BRIDGES LANE 3/10/2022 Commonwealth of Massachusetts RECEIVED
City/Town of MAR 10 2022
b System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
CEP 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. Syste cation: Left/Right front of house, Left/Right rear of house, Left/right side of hou e, Left
Rig side building, Left/ Right front of building, Left/Right rear of building, Under deck
on the computer,
use only the tab
key to move your Ad ss /
cursor-do not MA `
use the return
cvz ��
key. IT i own State Zip Code i
2. System Owner:
m
ame
lean `
Address(if different from location)
MA
CitylTown - ---- Stag� �3� �ip Code
Telephone Number `7
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 4Septic Tank ❑ Tight Tank ❑ Grep e Trap
Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
David Tiney — Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7. Locati n where contents were disposed:
LSUP Lowell Waste Water
Signature of Hauler Date