HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 171 LACONIA CIRCLE 8/2/2019 RECEIVED
.4ax Commonwealth of Massachusetts JAL 317019
City[Town own of TOWN OF NORTH ANDOVER
System Pumping Record � LTNDEPARTMENT
Form 4
DEP has provided this form for use-.by local Boards of-Health.Other forms may be Lsed,but theli
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 Inforri�ation
1. System Location: Left/Right front of house, Le / g t;rear of house Left/right side of house, LeftRight side of building, Left/Rigiit front of build'mg, e rear of building, Under deck
Address
City/Town l( l State Zip Code
2: System Owner. b
Name
Address(d different from location)
CitylTown State Zi
0-Cr-? ar
Telephone Number
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) �Pticnk ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ Noi
5. Condition of System:
6. System Pumped By:
Neil.Beteson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati ere ontente were disposed:
A L S Lowell Waste Water
Sign a Naul Data
MbrmCdocr 06/03 System Pumping Record•Page 1 of 1