HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 360 FOREST STREET 5/3/2022 '�L\'
Commonwealth of Massachusetts RECEIVED
City/Town of MAY 0 3 2022
b System Pumping Record r! ,,�.,vF N;1riTH ANDOVEk
Form 4 HLALTH 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
iocai 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 front of house, Left/ Right rear of house, Left/right side of house, Left
Right side of building, Left 1 Right front of building, Left/Right rear of building, Under deck
on the computer, O ST
use only the tab l
key to move your ddr ssn / (�
cursor-do not
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use the return key. City/Town State Zip Code
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2. Sys ern Owner:
Name
renm
Address(if different from location)
_ MA
City/Town State ip Cod
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Telephone Number
B. Pumping Record
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1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 4Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe): — - ---
4. Effluent Tee Filter present? ❑ Ye
,,�&o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
— o A A4 Y
6. System Pumped By:
David Tiney _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loc%' where contents were disposed:
LSD Lowell Waste Water
Signature of Hauler Date