HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 1429 OSGOOD STREET 5/10/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record MAY 10 2022
Form 4
• TOWN OF NORTH ANDOVER
AiTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other f� ms 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 t(
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right fron of house, Left/Right rear of house, Left/right side of house, Left
Rig t side of building, Left Right front o uildirig, Left/Right rear of building, Under deck
on the computer, ��-
use only the tab _
key to move your Ad re s
cursor-do not O g k t,� MA �!
use the return key. City/Town State Zip Code
,�n
2. rem Owne
ienm
Address(if different from location)
MA
City/Town Stayer � Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pu ed:
Date Gallons
3. Component: ElCesspool(s) ❑ Septic 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:
David Tiney _ _ _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. LgaatieQ where contents were disposed:
GLSD Lowell Waste Water
42
Signature of Hauler Date