HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 440 WINTER STREET 10/31/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of 0 C T 312022
System Pumping Record JOWN 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 tc
the local Board of Health or other approving authority.
A. Facility Inform'ation
1
1. System Location: Left/Right front of hou , Left ight rear of house, Left/right side of house, Left
Right side of building, Left/Right front of b ' ng, Left/Right rear of building, Under deck
on the computer, �e
use only the tab
key to move your Address _
cursor-do not `' �V Q MA
key the return City/Town State Zip Code
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2. !Pstem Owner:
Oy r
Name
nom
Address(if different from location)
MA
Cityrrown State 6])- , C63.7ode
Telephone Number
B. Pumping Record
1. Date of Pumping D(t� 2. Quantity Pumped: /
Gallons
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:
Orf"o l
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7- Lps tion where contents were disposed:
GLS Lowell Waste Water
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Signature of Hauler a