HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 434 BOXFORD STREET 8/9/2019 : Commonwealth of Massachusetts
_ City/Town of RECEIVED
System Pumping Record AUG 0 0 �o'g
Form 4
"' �''•y yt]WN OF NORTH ANDUVER
r DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Othedtis 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 Information _
1. System Location:4�Rig�6nhoofsbuildirig,
Left/Right rear of house, Left/right side of house, Left 1
Right side of building, Left/ Left/Right rear of building, Under deck
Address {
City/Town State Zip Code
2. System Owner.
Name
Address(&different from location)
CiWown State ip Code
-05
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0,110 if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc-
Company
7. Location w ontentawere disposed:
G L MHaul
Lowell Waste Water
Sign Date
t5form4.doaw 06/03 System Pumping Record•Page 1 of 1