HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 322 BOSTON STREET 7/6/2022 RECOVED
Commonwealth of Massachusetts
City/Town of JUL 0 6 2022
System Pumping Record YowN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DER 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
1, System Location: Left/Right front of house,-Cep/Righ ear of ho su eft/right side of house, Left
Right side of bullding, Left/Right front of building, Left/ g rear of building, Under deck
on the computer, � n
use only the tab �c�C t� �5p S �� ,�'• f1`,T
key to move your Address �—
cursor-do not MA
use the return Ci frown
key. ty State Zip Code
2. System Owner:
'hc��t �CQVI
Name
item
Address(if different from location)
MA
Cityfrown State Zip Code
(ell-7 — 742 —
Telephone Number
B. Pumping Record
1. Date of Pumping Date " 1.� Gallons
2. Quantity Pumped: I S L
Date
3. Component: ❑ Cesspool(s) V/Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? �s ❑ No If yes, was it cleaned? [�/Yes ❑ No
5. Observed condition of component pumped:
I�- ►emu l`��c
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
company
7. Location where contents were disposed:
G SD Lowell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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