HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 353 BOXFORD STREET 7/6/2022 RECEIVED
: Commonwealth of Massachusetts
City/Town of JUL 0 6 2022
System Pumping Record o TOWN OF NORTH ANDOVER
Form 4 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 your
local Board of Health to determine the forfn they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left g rear of hous Left/right side of house, Left/
Right side of building, Left/Right front of buildin' e g rear of building, Under deck
on the computer, 53 � u // �r C1/ / �
use only the tab 73 _ '��r p"( .T'-- �(/
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner:
Name
inn
Address(if different from location)
MA
City/Town State Zip Code—f
Telephone Number
B. Pumping Record
1. Date of Pumping Dat 2--�2. Quantity Pumped: canons
3. Component: ❑ Cesspool(s) [+Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes eNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
'&-A Eck ( V
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
company
7. Location where contents were disposed:
GLS Lowell Waste Water oe
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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