HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 117 BROOKVIEW DRIVE 7/31/2019 .Commonwealth of Massachusetts
City/Town of � �� �
System Pumping Record JUL 31 ZM
Form 4 TOWN OF NORTH ANDOvER
' HEALTH DEPARTMENT
DE-P has provided this form for use.by local Boards of Health. Other forms may *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 authoft.
A. Facility Informi ation
1. System Location: Left/Right front of house, Left/Right rear of house(L g t side of ouse Left
Right side of building, Left/Right front of building, Left/Right rear of but ding,
Address
CWTown State Zip Code
2. System Owner. /''�Ott C)
Name' /`---�
Address(if different from location)
Civrown State _ Code
Telephone Number
.B. Pumping K-ecord
1. Date of Pumping Date 2. Qu u Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? a�res El No. If yes, was it cleaned? es ❑ No
5. Conditions of System: —
�, �-� � L
S. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' re contents were disposed:
AD Lowell Waste Water
`-�LSA.
Sign a fl-lauloU Date
t5ibrrn4.doo-06103 System Pumping Record•Page 1 of 1
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