HomeMy WebLinkAboutHolding Tank - Septic Pumping Slip - 1429 OSGOOD STREET 10/18/2022 : Commonwealth of Massachusetts RECEIVED
. City/Town of
System Pumping Record OCT 1 s 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 forty!,check with you
local Board of Health to determine the forrh they use.The System Pumping Record must be submitted t(
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side of buildin Left/Right front of building, Left/Right rear of building, Under deck
on the computer,
use only the tab
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner:
r� D` �V e_�,r- G�CO y
Name
ream
Address(if different from location)
MA _
Citylrown State Zip Code
�\ �
Telephone Number
B. Pumping Record
1. Date of Pumping Cate ( 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspools Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
e
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD Lowell Waste Water
Si g auler