HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1264 SALEM STREET 4/19/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of APR 19 2022
s system Pumping Record TOWN OF'NORTH ANDOVER
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
t side building, Left/ Right front of building, Left/Right rear of building, Under deck
on the computer,
use only the tab 6
key to move your Address
cursor-do not K I{/ 6 MA Q/K
key.
use the return ity/Town -; state Zip Code
VQ 2. System Owner:
g n/
Name
renm
Address(if different from location)
MA
CitylTown Stag /,�.� � �Zip,Dode�
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: /5
Date Gallons
3. Component: ❑ Cesspool(s) ,,Keptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes, o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of /component pumped:
Y V�
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
Signature of Hauler Date