HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 129 CHRISTIAN WAY 4/19/2022 3ECEIVE'L'
Commonwealth of Massachusetts
City/Town of APR 19 2022
b System Pumping Record TOWN OF NORTH ANDOVEP
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may *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/ front se, Left/Right rear of house, Left/right side of house, Leff
Right side of buiidi , Le front building, Left/Right rear of building, Under deck
on the computer,
use only the tab
key to move your Ad5fess
�
cursor-do notyU'� y/
use the return MA
key. Citylrown State Zip Code
df�1 2. System Owner:
V2L�l
l._
} Name
rcnm
Address(if different from location)
MA
City/Town State � ` � ' �Zip3 de
Telephone Number
B. Pumping Record
tea,
1. Date of Pumping 2. Quantity Pumped: 1
Date � Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ 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 iort�where contents were disposed:
GL / Lowell Waste Water
_ 3 a �z
Signature of Hauler Date