HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 57 OLYMPIC LANE 8/20/2019 .J\_ Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record AUG 2 0 2019
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may 6e'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 �rear1. System Location: Left/Right front of iiou ft eft/right side of house, Left/
Right side of building, Left/Right front of b I tng, Lelding, Under deck
Address
Clty/Town State Zip Code
2. System Owner. Pee_,L)C
Name'
Address(ir different from location)
CityJTown StateZip Code
Telephone Number
B. Pumping Record
,+
1. Date of Pumping Date 2 Quantity Pumped: /d
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o !f yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where` ontenta were disposed:
L_ S Lowell Waste Water
LPMS- A.
Sign a i-Ihul Date
tftrm4.doc•06/03 System Pumping Record•Page 1 of 1