HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 CRICKET LANE 4/19/2022 Commonwealth of Massachusetts RECEIVED
City/Town of APR 19 2022
b System Pumping Record TOWN OF NORTH ANUGVEti
Form 4 HEALTH DEPARTviENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe 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.
i
A. Facility Information
1. System Location: Left/Right front of house, Left/ Rig of-louse, Left/right side of house, Lei
Right side of building, Left/ Right front of building, L /Right reari building, Under deck
on the computer, ,5' � o l� j�' `�'l Q
use only the tab ✓ ''t• �—
key to move your X ress
cursor-do not IU6] MA
use the return City/Town State Zip Code
key.
2. System Owner:
DeA
Name
ream
Address(if different from location)
MA
City/Town State ts dip Code
Telephon Nu ber /Ul
B. Pumping Record
D�L /S 1)
1. Date of Pumping 3- _ 2 Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grea$e Trap
❑ Other (describe): - -
4. Effluent Tee Filter present? ❑ Yeri
No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Le
6. System Pumped By:
David Tiney _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loc n where contents were disposed:
LSD owell Waste Water
-- 77 - _ z�,_�__ 2
Signature of Hauler Date