HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 536 FOREST STREET 5/3/2022 :IN- Commonwealth of Massachusetts RECEIVE!
City/Town of
s System Pumping Record MAY 0 3 ZM
Form 4
i UWfv Ur NORTH ANDUVER
REALTH DEPARTMENT
DEP has provided this form for use-by local Boards of"Health. Other forms maybe*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./right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
on the computer, 5t�L 3%_ ^ �
use only the tab /_ /�y �(1�
key to move your Address �� ��l�/rl'�L MA y D 7
cursor-do not /,d�►✓n
use the return
key. City/Town State Zip Code
2. Sy tem Owner:
Name
Address(if different from location)
MA
City/Town State ,I _ � � Zip Code
Telephone Number L7//77i2
B. Pumping Record f� a
Late of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grea$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. where contents were disposed:
GL Lowell Waste Wate
Signature of Hauler Date