HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 895 FOREST STREET 10/31/2022 ;-C\ Commonwealth of Massachusetts RECEIVED
City/Town of OCT 312022
System Pumping Record 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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted t(
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/ Right rear of houso, L / ight side of hous , Left
Right side of building, Left/ Right front of building, Left/Right rear of building,
on the computer, � � L: -�>+
use only the tab tl y
key to move your Address
cursor-do not N MA
use the return City/Town State Zip Code
key.
2. System Owner:
Name
enm "
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1 �
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) .9-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:
1Vl>/-M,�,l C
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. ntion where contents were disposed:
Lowell Waste Water
1 i
Signature of Hauler Date
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