HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 39 GRANVILLE LANE 10/31/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record •. OCT 312022
Form 4 TOWN OF NOR-r;i ANDOVEk
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 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. System Location: Leh/ , Left/Right rear of house, Left/right side of house, Left
on the computer,
Right side of building, Leftiija�' of building, Left/Right rear of building, Under deck
use only the tab �� G �.,,,il4 f�
key to move your Addr r-
use -do not / . �V1
use the return MA
key. CitylTown State
Zip Code
2. System Owner: `
rab JC,C(�� f6-T;AJ O
Name
Isom
Address(if different from location)
MA
City/Town State Zip Code
& 17 _�57/k_� / ?�0
Telephone Number
B. Pumping Record
1. Date of Pumping �U k)� 2. Quantity Pumped:Date Gallons
3. Component: ❑ Cesspool(s) ET"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:
_&rn'6( -
6. System Pumped By:
Jon Kirmil Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company —
7. Location where contents were disposed:
L Lowell Waste Water
Signafnre at tiler
Date�