HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 PHEASANT BROOK ROAD 7/31/2019 Commonwealth of Massachusetts RECEIVED
City/Town of JUL 31 2010
System Pumping Record TOWN OF NORTH ANDOVER
Fo1 m 4 WEALTH 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 your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Informs ation
i
1.. System Location: Left/Right front of Pious , Le , tg rear o ouse, •/right side of house, Left 1
Right side of building, Left/Right front of I ding, Left o uiidhng, Under deck
Address PAqso,�4- 1z
CitylCown State ` Zip Code
2. System Owner. c
Name'
Address(if different from location)
CitylTown State- Zip Cod
13 0e
Telephone Number
.B. Pumping Record
1. Date of Pumping Dam 2. Quantity Pumped:
Gallons
3. Type-of system:y stem: ❑ Cesspool(s) peptic Tank ❑ Tight Tank
❑ Other(describe):
i
4. Effluent Tee Filter present? ❑ Yes a o If yes, was it cleaned? 0- Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. ZeHaulw
contents-were disposed:
Lowell Waste Water
sDate
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