HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 600 FOSTER STREET 5/10/2022 _ �ECEtV tt�
� Commonwealth of Massachusetts
City/Town of SAY 10 2o22
System Pumping Record •SOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe bsed, 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$ystem 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/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
on the computer, _1 /
use only the tab
key to move your Address
cursor-do not _ MA
use the return City/Town key. ty State Zip Code
2. System Owner:
e
Name \.01A
rram
Address(if different from location)
MA
City/Town State Zip Code
If-I"Ll L( — I ST S
Telephone Number
B. Pumping Record
1. Date of Pumping 011 4� ° 2. Quantity Pumped: Sd
Date Gallons
3. Component: ❑ Cesspool(s) VS- Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? [ Yes ❑ No If yes, was it cleaned? &K/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. Location where contents were disposed:
C
SD Lowell Waste Water
Signature of Hauler Date Q F s
Signature of Receiving Facility(or attach facility receipt) Date
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