HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 80 LOST POND LANE 8/20/2019 : Commonwealth of Massachusetts RECEIVED
City/Town of AUG 2 0 201q
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms 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: Left/Right front of house, L igh rear of . , Left/right side of house, Left
Right side of building, Left/Right front of buildin , 'ght rear of building, Under deck
Addres LOS+
Cityrrown State Zip code
2. System Owner. _ Q
Name
Address(i different from location)
City/Town
Telephone Number
B. Pumping Record
a-
I 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 No 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 where contents-were disposed:
S: Lowell Waste Water
Sign afHikulev Date
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