HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 SUGARCANE LANE 5/3/2022 :�L\ Commonwealth of Massachusetts RECEIVED
City/Town of
b system Pumping Record 10, MAY o 3 2022
Form 4
• TOWN OF NORTH ANDOT
gEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other orms 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
f�1'gfi s e building, Left/ Right front of building, Left/Right rear of building, Under deck
on the computer, Q 3
use only the tab
key to move your Addres—s (�
cursor-do not /W l�� [, (,&� _ MA Yj
use the return key. City/Town State Zip Code
2. System((Owner:
e 4X41J
$t� Name
rerun J
Address(if different from location)
MA
Cityfrown Sta���_� Zip Code
Telephone Number
B. Pumping Record
rlv—
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 4septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ---
4. Effluent Tee Filter present? ❑ Yes L � 0 If yes, was it cleaned? El Yes ❑ No
5. Observed condition of component pumped:
► 26KhqT--� I
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. rLSQ7
where contents were disposed:
Lowell Waste Water
V j K��
Signature of Hauler Date