HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 327 FOREST STREET 4/19/2022 'IN
Commonwealth of Massachusetts RECEIVED
City/Town of APR 19 2022
` System Pumping Record TOWN OF NORTH ANDOVER
Form 4 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 tt
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left]Wqear qf4iouqla, Left/right side of house, Left
Right side of buildin Left/�front of buildiri , eft 1 g rear building, Under deck
on the computer, ��? d W / ��use only the tab � / _
key to move your Addres
cursor-do not /Cog /� ` MA_
use the return City/Town r� — State Zip Code
key.
VQ 2. Sys em Owner:
Name
ienm
Address(if different from location)
MA
City/Town Sta�?v
Zip Code
/w s �
Telephone Number
B. Pumping Record 15061
1. Date of Pumping Date 2. Quantity Pumped: 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 pumped:
6. System Pumped By:
David Tiney _ _ _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
SDI Lowell Waste Water
Signature of Hauler Date