HomeMy WebLinkAbout- Septic Pumping Slip - 208 OLD CART WAY 10/19/2018 Commonwealth of Massachusetts RECEIVED
City/Town of M11 19 2018
System Pumping Record TOWN OF NORTH ANDOVER
Fonn 4 HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms;maybe'used, but the
Information,must be substantially the tame as that provided here. Before using.this form,check with your
[ocail Board of Health to determine the forth they use. 'The System Pumping Record must be submitted tc)
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. System Location: Leh/Right front of house, Left I Right rear of house, Left/<MQM—e—qfhoq-9p,, Left I
Right side of building, Left I Right front of building, Left/Right rear(if building, NnTe—rdi-qk—
Address )
—-- ----
Cityfrown J late Zip Code
2. System Owner r\
Marna'
Address Of different from location)
Citynown stater Zip Code
Telephone Number
Pumping Record
1. Date of Pumping i o ucintity Pumped: I
Dak Callon
0
3. Typ&of system: E] Cesspool(s) Septic Tank E] Tight Tank
[I Other(describe):
4. Effluent Tee Filter present? [] Yes Plo If yes,was it cleaned? ® 'Yes n No
5. Condition of System•
, �
A)IOLO�2 lil Gnli
6. System Pumped By:
Neil.Batesbn F6821
Name Vehicle License Number
Bateson Enterprises lnc�
Company
7. Location where contents-were disposed:
4, S.�) Lowell Waste Water
. . ..... ...................
Sign Hlbule Date
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