HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 84 CANDLESTICK ROAD 4/19/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of APR 19 2022
b System Pumping Record 10 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/Right rear of house, Left/right side of house, Lei
Right side of building, Left/Ri front o uildirig, Left/Right rear of building, Under deck
on the computer, / + /
use only the tab 1, C p/Q 1 l'
key to move your Addy s` n
cursor-do not v�/fv / Jhr� MA 6 1 1�
use the return City/Town ��v State Zip Code
key.
2. System Owner:
Na e
Address(if different from location)
MA
City/Town State jip Code
Telephone Number —�
B. Pumping Record
1. Date of Pumping Date �_2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes • o 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. Location where contents were disposed:
GLSD Lowell Waste Water
` s C�
Signature of Hauler Date