HomeMy WebLinkAboutSeptic Tanks - Septic Pumping Slip - 73 FARNUM STREET 8/9/2019 Commonwealth of Massachusetts
City/Town of .
i syateim Pumping-Record AUG o a 201
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has-provided'this form for use-by local Boards of-Health. Other forms maybe*used,but the
•,,; information•crust be sutastantially the same as That provided here. Before using.this form,check with your
local Board of Health to determine the forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. inforitnation
1. System Location: Left/Right front-of house, Left ht rear of hous , Left./right side of house, Left
i Right side of building, Left/Rigl't front of building, Left/Right rear of building, Under deck
Address
City/rown State - Zip Code
Z. System Owner.
Name'
Address(if different from location)
CivTown Stater Zip Cod
Telephone Number d
B. Pumping Record
1. Date of Pumping 2..Quantity Pumped: Eton/
Date
r
3. Type-of system: ❑ Cesspool(s) MISeptic TankS ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 040 If yes,was it cleaned? ❑ Yes ❑ No,
'5. 'Condition of System:
6. System Pumped By:
Neil.Batesoct • F5821
Name Vehicle Ucense Number
Bateson Ehterprises Inc'
Company
1 •
I 7. LoTa �
e contents-were disposed:
_
rmL Lowell Waste Water
r—
SignAtuTe 9f Heul Date
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