HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 130 MARIAN DRIVE 4/19/2022 r
RECEIVED
Commonwealth of Massachusetts APR 19 2022
City/Town of
System Pumping Record • TOWN OF NORTH ANDOVEH
U1
HEALTH DEPARTMENT
Form 4
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
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/R ear of use, Left/right side of house, Left
Right fide of building, Left/Right front of buildiri eft/ 'g t rear Of building, Under deck
on the computer, '/'
use only the tab _ '_'
key to move your Add%less /
cursor-do not �!/J" MA �e!
use the return
key. City/Town State Zip Code
2. S tem/Owner:
�m l( e7 /� - -
Name
�enm
Address(if different from location)
MA
CityrFown State `b _ Zi ode
Telephone Number 3
B. Pumping Record
1. Date of Pumping v C ' 2. QuantityPum / �u
p g Date pedi Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe): -
4. Effluent Tee Filter present s ❑ 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. Lo ion where contents were disposed:
GLSD Lowell Waste Wat
- a
Signature of Hauler Date