HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 SHANNON LANE 4/19/2022 Commonwealth of Massachusetts RECEIVELI
City/Town of APR 19 2022
System Pumping Record •
Form 4 TOWN OF NORTH ANDOVEP
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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right f tipuse, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left ight fron building, Left/Right rear of building, Under deck
on the computer, �I ,' � /��/►
use only the tab i1 [�"
key to move your Address
cursor-do not L MA
use the return ityrrown State Zip Code
key.
2. Yam
em Owner:
Q
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Address(if different from location)
MA � Zip City/Town — --- --- ----- - SpI(/ e
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
CJ ►�
Date Gallons
3. Component: ❑ Cesspool(s) �epticTank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — --
4. Effluent Tee Filter present? ❑ Yes VNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pump d:
6. System Pumped By:
David Tiney _ Mass F5821 _
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Locat' where contents were disposed:
SD Lowell Waste Water
Signature of Hauler AV Date