HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 837 DALE STREET 4/19/2022 ,� Commonwealth of Massachusetts RECEIVELI
City/Town of
System Pumping Record APR 19 2022
Form 4 TOWN OF NORTH ANDOVEE
• HEALTH DEPARTMENT'
DEP has provided this form for use-by local Boards of Health. Other forms may be*used,but the
informadon,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 fro Buse, Left/Right rear of house, Left./right side of house, Let
Rig t side of buildiq,nLe fight front f building, Left/Right rear of building, Under deck
on the computer'
use onlylythethe tab v _
key to move your A !r,
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use the return ity/Town State ip Code
key.
2. S em Owner:
L
Name
rerun
Address(if different from location)
MA
Cityrrown _States /Zip C
n L—erode
Telephoe /`%,C.•
B. Pumping Record
1. Date of Pumping O1� - 2. Quantity Pumped:
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 pu ped:
6. System Pumped By:
David Tiney _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. a )Lowell
here contents were disposed:
(;o—c
LSD Waste Water
3---
Signature of Hauler Date