HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 191 GRANVILLE LANE 7/31/2019 Commonwealth of Massachusetts RECEIVED
. City/Town of JUL 31 Z0Aq
System Pumping Record TOWN®F NORTH ANDOVER,
Form 4 HMj"DEPARTMENT
DEP has provided this form for use=by local Boards of-Health. Other forms maybe*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 forrn they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address UA V-CXS
Cityrrown State Zip Code
2: System Owner.
Name
Address(if different from location)
Cityfrown State �jp.Coda
Telephone Number
.B. Pumping Record
1. Date of Pumping gate 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) e-p-W Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Leo If yes,was it cleaned? ❑- Yes ❑ No
5. Condition of System:
IA_
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
company
7. Lo re contents-were disposed:
G L S Lowell Waste Water
ISIgnRtHbaudImu,
Date
tftrm4.doc•06/03 System Pumping Record•Page 1 of 1