HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 427 WINTER STREET 4/19/2022 Commonwealth of Massachusetts RECEIVEC,
City/Town of
b System Pumping Record APR 19 2022
Form 4 TOWN OF NORTH ANDOVEF-
HEALTH DEPARTMENT
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 you
local Board of Health to determine the form they use.The,System Pumping Record must be submitted t(
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left I Right front of house, Left 1 rear of sa, Left/right side of house, Left
Right side of building, Left/ Right front of buildiri , Left 'Right(Ctar.01 building, Under deck
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use the return tity/Town �' State Zip Code
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2. System Owner:
�IA it)
Name --
Brun
Address(if different from location)
MA
City/'Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantityp Pum ed: Cd�
p g Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Greage Trap
❑ Other (describe): --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
David Tiney _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
LSD Lowell Waste Water
Signature of Hauler Date