HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 21 EASY STREET 4/19/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of APR 19 2022
System Pumping Record 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 your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locat lonz'C /RightTronit of douse_1di t/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
on the computer,
use only the tab k.
key to move your Address
cursor-do not MA
use the return Ci /'town
key. h' State Zip Code
2. System Owner:
ray
Name
Address(if different from location)
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Quantity Pumped: Ganonst d
3. Component: ❑ Cesspool(s) (3. 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 �omponent pumped:
6. System Pumped By:
Jon Kirmil __ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
company
7. Lpeetiorl where contents were disposed:
GL Lowell Waste Water
7 t �
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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