HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 58 PADDOCK LANE 7/6/2022 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record JUL 0 6 2022
Form 4 TUA/N 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 Informs ation
1. System Location: Left/Right front of house, Left/Right rear of house, Left 1019A side of house,'Left
Right side of building, Left/Right front of building, Left/Right rear of building, n er deck
on the computer,
use only the tab ON -
key to move your Address
cursor-do not MA
use the return City/Town
!T
key. h' own State Zip Code
2. System Owner:
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1A�a S
Name `
r6em
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number e
B. Pumping Record
1. Date of Pumping DatL 2 2 2 Quantity Pumped: canon
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:
N0TVVIII-dq�
6. System Pumped By:
Jon Kirmii Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
company
7. Location where contents were disposed:
GLS Lowell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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