HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 117 BROOKVIEW DRIVE 4/19/2022 RECEIVED
Commonwealth of Massachusetts APR 19 2022
City/Town of
System Pumping Record ♦ TOWN OF NORTH ANDCVEF+,
�/ in p g HEALTH DEPARTMENT
Form 4
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 lnfort'ation
1. Syste tion: Left/Right front of house, Left/Right rear of house, Left/right side of hou e, Left
Rig side building, Le/ft//Right front of building, Left/Right rear of building, Under deck
on the computer,
use only the tab
key to move your A dre s � / ,
cursor-do notMA
key. (�
use the return /Town 'T State Zip Code
2. Sys m Ownear:
�w V —
Name
Bnm
Address(if different from location)
MA
Cityrrown State �® Zip Code
11b tom G
Telephone Number
B. Pumping Record V-
/
Co
1. Date of Pumping ate — 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ 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 do here contents were disposed:
LSD_.) Lowell Waste Water
Signature of Hauler Date