HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 142 DUNCAN DRIVE 7/6/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record •. JUL 0 6'2022
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
1. System Location: Left/Right front of house, Left/Right rear of house righ Ide o eft
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
on the computer, (� /+ ('
use only the tab _ 1 Y�c �((�_ 1 /V' r
key to move your Address
cursor-do not MA
use the return Ci rr
key. h' own State Zip Code
2. System Owner: C
Name
seam
Address(if different from location)
MA
City/Town State Zip Code
,-{
Telephone Number
B. Pumping Record
1. Date of Pumping °1a a 2. Quantity Pumped: S a o
Date Gallons
3. Component: ElCesspool(s) Septic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 9/No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition f component pumped:
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GL Lowell Waste Water
Signature of Hauler Date r �
Signature of Receiving Facility(or attach facility receipt) Date
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