HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 700 MIDDLETON STREET 4/19/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of APR 19 2022
System Pumping Record TOWN OF NORTH ANDOVEH
Form 4 HEALTH 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 yo
local Board of Health to determine the form they use. The System Pumping Record must be submitted
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left I ear o , Left I right side of house, Lei
Rig a of building, Left/ Ri ht front of buildih eft t rear o ilding, Under deck
on the computer,
use only the tab
key to move your A dr ss q�
cursor-do not MA
use the return Citylrown State p Code
key.
2. System Owner:
VQ
i N me
i
wnm
Address(if different from location)
_ _ MA
City/Town State` /-)L Zipode
Telephone Number Q+�(�d^
B. Pumping Record
YDate of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -
4. Effluent Tee Filter present? )4 es ❑ No If yes, was it cleaned? kyes ❑ No
5. Observed condition of component pump d:
6. System Pumped By:
David Tiney _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Lo where contents were disposed:
LSD Lowell Waste Water
Signature of Hauler Date