HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 72 PADDOCK LANE 5/20/2022 r1ECENED
Commonwealth of Massachusetts
City/Town of 2 p NZZ
MAY
System Pumping Record •
Form 4 TOwN OF NURfH ANDOVER
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 tc
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/ rear of h s, Left/right side of house, Left
Rig ide of b ildin , Left/Right front of buildlri , Left g ear building, Under deck
on the computer, /
use only the tab Y
key to move your A ess /� �/! ,
cursor-do not 'K '*k�' - MA V/d i
use the return Ci /Town
key. ty State Zip Code
2. System70n r:
r�
me
aam ,
Address(if different from location)
MA
City/Town State Zip Code
..? ;�l- 22
Telephone Number
B. Pumping Record ,)
1. Date of Pumping Date J L 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye94 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
n
� P
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loc ' where contents were disposed:
LSD Lowell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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