HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 767 JOHNSON STREET 5/10/2022 Commonwealth of Massachusetts �ECE'v�r
City/Town of
System Pumping Record 10MAY 1 a2o22
Form 4 fOWN OF N( Eppl ANDOVER
HEA1-TH 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/Right rear of house, Left/'rig -ide of house LVft
Right side of building, Left/Right front of building, Left/Right rear of building, Under ecd ck on the computer, f �v
use only the tab :�]("_7 ckd S6)-j
key to move your Address -�
cursor-do not MA
use the return Cityfrown
State
Zip Code
2, System Owner:
rs
Name yj
role
Address(if different from location)
MA
Cityrrown State Zip Code
Telephone Number S
B. Pumping Record
1. Date of Pumping Date fSeptic
2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 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:
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Logatkin where contents were disposed:
GLS Lowell Waste Water
Signature of Hau er 7 �
Date
Signature of Receiving Facility(or attach facility receipt) Date
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