HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1429 OSGOOD STREET 6/13/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record JUN 13 2022
Form 4 TOWN OF NORTH ANDOVER
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 tc
the local Board of Health or other approving authority.
A. Facility Information
i. Syst�satioa:_Ln�ft/Right front of house, Left/Right rear of house, Left/right side of house, Left
i Right side of buildings Left/Right front of building, Left/Right rear of building, Under deck
on the computer, ` / C 1_
use only the tab J
key to move your Addr ss
cursor- not _ MA
use the return
urn City/Town State
key. Zip Code
2. System Owner:
01 vex' 6 \coup
Name
Address(if different 4rom location)
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of P umping pate 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes "� If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition component pumped:
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. oc tion where contents were disposed:
SD a as ater
rt�------
Signature uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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