HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1432 SALEM STREET 5/20/2022 RECENED
Commonwealth of Massachusetts
City/Town of MAy 2 0 2022
b system Pumping Record OF NORTTMH pNDOVER
�C
EPPR T
FOForm4 HEALvo D EN
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 t(
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Rig f+teuse, Left/Right rear of house, Left/right side of house, Left
Right side of building, /Right front of b ilding, Left/Right rear of building, Under deck
on the computer,
use only the tab
key to move your Addre§s MA ox�/
/
cursor-do not Q� �
use the return City/Town State Zip Code
key.
VQ 2. Sy tem Owner:
Name
renm
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
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. Lo io where contents were disposed:
GLSD Lowell Waste Water Q
4 �2
Signature of Hauler Date