HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1429 OSGOOD STREET 4/19/2022 Commonwealth of Massachusetts RECEIVED
City/Town of APR 19 2022
b System Pumping Record •
Form 4 TOWN OF NORT,' ANDOVEfs
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may *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 ' h#fr house, Left!Right rear of house, Le#t/right side of house, Left
on the computer,
Right side of building ht front building, Left/Right rear of building, Under deck
use only the tab
key to move your Addr ss
cursor-do not 'rf `/�? Q2'-P-�� MA
use the return ity/Town State Zip Code
key.
2. System Owner:
rib
Name
Address(if different from location)
MA
City/Town Sta /1� Il M qd�
p�"I7
Telephone Number
B. Pumping Record 3
1. Date of Pumping Date 2. Quantity Pumped: Gallons
G
3. Component: ❑ Cesspool(s) J�'Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -�I -
4. Effluent Tee Filter present? ❑ Yes/mpp
o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component p :
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
Sig atu4 f Hauler Date