HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 BROOKVIEW DRIVE 5/10/2022 ,jFcENED
Commonwealth of Massachusetts
City/Town of MAY 10 nzz
System Pumping Record tN OF N(3RTH ANDO\/Eh
OW
Form 4 HEALTH OEPARTMENT
DER 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 Locatloirl:e`ft--hiot front of house,.Laft/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front oftiuiiding, Left/Right rear of building, Under deck
on the computer, �
use only the tab ��(
key to move your Address ---
cursor-do not
use the return _ MA
key. City/Town State Zip Code
2. System Owner:
Name
rrnm
Address(if different from location)
_ MA
City/Town State Zip Code
r2S6 _ 0-3 X5T
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: S 0
Date Gallons
3. Component: ❑ Cesspool(s) WSeptic 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:
A)or*^', k ( (n�if
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loc ' where contents were disposed:
OGL Lowell Waste Water
Signature of Hauler DateC�
Signature of Receiving Facility(or attach facility receipt) Date
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