HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 1429 OSGOOD STREET 5/20/2022 : Commonwealth of Massachusetts RECEIVED
City/Town of MAY 2 0 2022
b System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
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 forrh 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 front of house, Left/Right rear of house, Left/right side of house, Left
Righ side of building, eft/Rig t front of building, Left/Right rear of building, Under deck
on the computer, ' 0� I
use only the tab LLL
key to move your Address `
cursor-do not /��� MA 10C 1.
use the return City/Tow �'' State Zip Code
key.
,n
2. System Owner:
Q, Itik,
Name
renm
Address(if different from location)
MA
CityrTown State Zip Code
Telephone Number
B. Pumping Record �
45�1. Date of Pumping Da e 2. Quantity Pu ed:
Gallons
3. Component: ❑ Cesspool(s) El Septic Tank Tight Tank ❑ Grea$e 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. Loc where contents were disposed:
LSD I Lowell Waste Water
Signature of Hauler Date