HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 192 STONECLEAVE ROAD 5/20/2022 :�L\ Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record MAY 2 0 2022
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENU1
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/Right front of house, Left/RI h ousa, Left/right side of house, Left
Right side of building, Left Right front of building, L ht rear o uild'mg, Under deck
on the computer,
use only the tab
key to move your /AM2K
cursor-do not i/� MA
use the return key. City/Town State Zip Code
2. System Own r:
Name
Bnm "
Address(if different from location)
MA
City/Town State ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Ye 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. Lo ere contents were disposed:
GLS Lowell Waste Water
Signature of Hauler Date